H1N1 Updates (09.11.2009)

Please Check Back Daily As Updates Become Available … (see below for earlier updates)

*** FRIDAY, SEPTEMBER 11, 2009 ***

Pandemic H1N1 Presentations:

• Michele M. Ginsberg, MD, San Diego County, HHSA, Community Epidemiology Branch
• Patricia McVay, MD, San Diego County, HHSA, Public Health Laboratory
• Mark H. Sawyer, MD, and Robert Peters, PhD, MD

*** THURSDAY, SEPTEMBER 10, 2009 ***

Pandemic H1N1 Updates

• Executive Director's Note: I most strongly urge you to view the video (click here) and consider becoming a vaccinator!
• From the County Public Health Officer: The coming fall influenza season will present the challenge of the simultaneous circulation of H1N1 and seasonal influenza viral strains. Many providers may already have seasonal flu vaccine. The County will have its allocation from the State in late September. The seasonal flu vaccine is not expected to protect against the pandemic H1N1 flu. H1N1 flu vaccine is expected to be available in late October or early November. The H1N1 flu vaccine will be made available at no cost. Vaccine providers will, however, be able to charge an administrative fee.
• Providers can register with the State to become vaccinators for the H1N1 vaccine. You can register to become a vaccinator at The California pandemic H1N1 influenza vaccine website. By registering at this site, providers will be able to order vaccine, receive vaccine information and updates, and report their use of H1N1 vaccine. In order to register, you will need to provide your medical license number and an estimate of the number of patients in your practice in the priority groups for H1N1 vaccine. Complete instructions for registering are available on the website
• Every physician who sees patients should click here to view this 16-minute webinar: "Pandemic H1N1 Influenza Vaccine."

*** FRIDAY, MAY 8, 2009 ***

Updated List of Tamaflu Pharmacy Location

*** WEDNESDAY, APRIL 29, 2009 ***

Websites

The best single source of authoritative information is still the CDC's website.

Please consider signing up for the San Diego Emergency Medical Alert Network, EMAN.

News

The swine flu epidemic has just been upgraded by the World Health Organization to phase 5. WHO describes six stages leading to an official flu pandemic. Phase 4 is sustained human infection. Phase 5 is human-to-human contact and infection in at least two regions. Phase 6 is a true pandemic, with widespread human infection. There have been 91 confirmed cases in the United States, 14 in California, and one death (in Texas); however, that Texas death was not from a patient who was infected in the United States.

CDC Recommendations

Click here for the most recent CDC recommendations, including antiviral dosages.

Cautions on the Use of Antiviral Medications (From the San Diego County Public Health Office)

1. People who are experiencing uncomplicated, influenza-like illness should not be receiving anti-viral treatment.
2. Given the limited amount of antiviral therapy for influenza, priority will be given to treatment over chemoprophylaxis.
3. To avoid the development of resistance in any individuals please, do not deviate from the standard dosage protocols, and encourage patients to complete prescribed courses. The standard dosage protocols can be found here.

Distribution of Emergency Anti-viral Supplies (From the San Diego County Public Health Office)

Plans are in place to distribute the recently received supply of anti-viral medications to healthcare facilities in the community today, April 29, 2009. Facilities that will be receiving supplies today include hospitals, community clinics, and university student health centers.

The supply of anti-virals should be used according to the following CDC recommendations. Patients eligible for anti-viral therapy are listed below in priority order

For Treatment

1. Hospitalized confirmed or probable cases of swine influenza who are admitted to an intensive care unit or have evidence of respiratory failure.
2. Hospitalized confirmed or probable cases of swine influenza who are at high-risk for influenza complications.
3. Any hospitalized confirmed or probable case of swine influenza.
4. Non-hospitalized confirmed or probable cases of swine influenza who are at high-risk for influenza complications.
5. Other non-hospitalized confirmed cases of swine influenza if treatment can be started within 48 hours of symptom onset.
6. Close contacts of a confirmed or probable case of swine influenza with ILI who are at high-risk for influenza complications.
7. Healthcare workers or public health workers with ILI who have had close contact with a confirmed or probable case of swine influenza.
8. Any close contact with ILI of a confirmed or probable case of swine influenza.
9. Suspected cases of swine influenza who are at high-risk for influenza complications.

For Chemoprophylaxis

1. For household close contacts of a confirmed or probable case who are at high-risk for complications of influenza.
2. School children who are at high-risk for complications of influenza who had close contact with a confirmed or suspected case.
3. Healthcare workers or public health workers who had unprotected close contact with an ill confirmed case of swine influenza A (H1N1) virus infection.

Definitions

• Close contact is defined as within about six feet of an ill person who is a confirmed or suspected case of swine influenza A (H1N1) virus infection during the case’s infectious period.
• High-risk persons include persons 65 or older, children younger than five years old, pregnant women, children on long-term aspirin therapy, persons with an immunosuppressive condition (including taking chronic immunosuppressive medication), and persons with certain chronic medical conditions, including cardiac, pulmonary, renal, liver, hematologic, metabolic, or neurologic/neuromuscular disease. Children ≤ one year old will have to be addressed in a case-by-case basis as oseltamivir is not licensed for this age group.

Obtaining Tamiflu Outside of Hospitals, Community Clinics, and University Student Health Centers

The plan to distribute Tamiflu to other than hospitals, community clinics, and university student health centers is being worked on by the County. The County is aware of SDCMS’ concerns that pathways to Tamiflu outside of hospitals, community clinics, and university student health centers need to be expeditiously established. We will inform you as soon as these pathways are provided by the County.

*** MONDAY, APRIL April 27, 2009 ***

CDC Website

News

• As of 5:00 p.m. today, there are five confirmed cases of human swine influenza A (H1N1) infection in San Diego County. A local press release and video is available at here.
• According to the CDC, 44 confirmed cases have been reported in the United States (11 in California, 2 in Kansas, 28 in New York City, 1 in Ohio, and 2 in Texas). To receive automatic email updates regarding case count and investigation updates from the CDC, click here [select option on right side of the page].
• The WHO director-general raised the level of influenza pandemic alert to phase 4. An explanation of the different WHO pandemic influenza phases is available here.

Antiviral Dosing

If antivirals are indicated, click here for details on antiviral dosing.

Frequently Asked Questions As of Today

Here are some questions and answers from today, as well as some constructive suggestions. We are in a fluid environment, so today’s answers may be superseded tomorrow.

Q. What defines influenza-like illness (ILI)?
A. Fever >37.8°C (100°F) plus cough or sore throat.

Q. What should I tell my patients if they call with suspected ILI?
A. Persons who experience ILI and wish to seek medical care should contact their healthcare providers to report illness (by telephone or other remote means) before seeking care at a clinic, physician’s office, or hospital. Persons who have difficulty breathing or shortness of breath, or are believed to be severely ill, should seek immediate medical attention. Household contacts of persons with symptoms consistent with swine influenza should remain home at the earliest sign of illness, minimize contact in the community to the extent possible, and designate a single household family member as the ill person’s caregiver to minimize interactions with asymptomatic person. Patients should be referred to the CDC's Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home.

Q. What precautions should I take in my waiting room?
A. Practice the same “infection control measures” that you would for any other contagious infection seen in your office. If you have a separate waiting room, have patients go there first, put on masks (droplet precautions so far per the CDC) and then treat them per your normal protocol. If you do not have the luxury of two waiting rooms, then have patients put on a mask on arrival in your waiting room.

Q. What should I do if I suspect a patient in my office has ILI?
A. Patients with flu-like symptoms (without underlying comorbidities, diabetes, cardiac issues, etc.) should return home with supportive care for a week from onset start of their symptoms or at least 24 hours after symptoms have resolved, whichever is longer. If patients present with pneumonia or have severe underlying disease, or are elderly nursing home patients, consider sending them to the emergency room for likely admission. Patients may be referred to the CDC’s Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home.

Q.  Who should get tested for swine flu?”
A. Considering the virus is common in the community and to preserve resources, San Diego County Public Health recommends testing be reserved for hospitalized patients, healthcare workers, contacts identified, and other situations as determined necessary. This testing guidance may be modified if circumstances change.

Q. How do I get the viral medium and Dacron swabs for the nasopharyngeal (NP) samples if I suspect swine flu?
A. If you don’t have them in stock in your office, then don’t worry about taking the samples.

Q. If I have the materials to do NP samples, what are the instructions?
A. Click here for the form to be attached to the NP sample, along with sampling instructions. Click here are the instructions for NP testing.

Q. If I have an NP sample, how do I get it to the Public Health Lab?
A. Call County of San Diego Community Epidemiology at (619) 515-6620. After hours, page CEB on-call staff at (858) 565-5255. They will pick up. And remember to keep the samples refrigerated, not frozen.

Q. Should we send NP samples to commercial labs if we can’t get through to San Diego Public Health?
A. In general, no. If applicable, contact your hospital infectious disease officer/microbiology lab/medical staff for additional hospital specific guidance on testing.

Q. How do you handle your staff?
A. If you suspect that a staff member has or may be infected, consider droplet precautions (masks) for this individual. Staff who have symptoms of ILI should stay at home.

Comments and Suggestions From Today

• Since it is unknown whether the influenza rapid tests for human influenza A:H1N1 will be equivalent for swine influenza A:H1N1, the influenza rapid tests should not be used to screen for swine influenza.
• Antiviral treatment is recommended for young children, the elderly, and people at risk for severe complications. However, most people with ILI do not need to take antivirals. Recommendations for the utilization and distribution of Tamiflu are still being worked out.
• Amantadine and rimantidine are not effective against swine flu.
• Wash your hands, wash your hands, wash your hands. Cover the cough. Place more hand soaps and masks in your office. Practice social distancing, stay 3–6 feet away from individuals, do not shake hands. Clean commonly used surfaces with antiseptic wipes (phones, door knobs, computer keyboards, etc.).

To sign up for electronic updates directly from San Diego County Health and Human Services Agency, click here.

CDC Guidance for Facemask and Respirator Use

Click here for the Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been Detected, excerpted below:

Information on the effectiveness of facemasks and respirators for the control of influenza in community settings is extremely limited. Thus, it is difficult to assess their potential effectiveness in controlling swine influenza A (H1N1) virus transmission in these settings. In the absence of clear scientific data, the interim recommendations below have been developed on the basis of public health judgment and the historical use of facemasks and respirators in other settings.

In areas with confirmed human cases of swine influenza A (H1N1) virus infection, the risk for infection can be reduced through a combination of actions. No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings.

When it is absolutely necessary to enter a crowded setting or to have close contact with persons who might be ill, the time spent in that setting should be as short as possible. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. A respirator that fits snugly on your face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through a respirator for long periods of time. More information on facemasks and respirators can be found here.

When crowded settings or close contact with others cannot be avoided, the use of facemasks or respirators in areas where transmission of swine influenza A (H1N1) virus has been confirmed should be considered as follows:

1. Whenever possible, rather than relying on the use of facemasks or respirators, close contact with people who might be ill and being in crowded settings should be avoided.
2. Facemasks should be considered for use by individuals who enter crowded settings, both to protect their nose and mouth from other people’s coughs and to reduce the wearers’ likelihood of coughing on others; the time spent in crowded settings should be as short as possible.
3. Respirators should be considered for use by individuals for whom close contact with an infectious person is unavoidable. This can include selected individuals who must care for a sick person (e.g., family member with a respiratory infection) at home.

These interim recommendations will be revised as new information about the use of facemasks and respirators in the current setting becomes available.

For more information about human infection with swine influenza virus, visit the CDC Swine Flu website.

Definitions:

• FACEMASKS: Unless otherwise specified, the term “facemasks” refers to disposable masks cleared by the U.S. Food and Drug Administration (FDA) for use as medical devices. This includes facemasks labeled as surgical, dental, medical procedure, isolation, or laser masks. Such facemasks have several designs. One type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the nose bridge, and may be flat/pleated or duck-billed in shape. Another type of facemask is pre-molded, adheres to the head with a single elastic band, and has a flexible adjustment for the nose bridge. A third type is flat/pleated and affixes to the head with ear loops. Facemasks cleared by the FDA for use as medical devices have been determined to have specific levels of protection from penetration of blood and body fluids.
• RESPIRATOR: Unless otherwise specified, “respirator” refers to an N95 or higher filtering facepiece respirator certified by the U.S. National Institute for Occupational Safety and Health (NIOSH).
• CLOSE CONTACT: Three feet has often been used by infection control professionals to define close contact and is based on studies of respiratory infections; however, for practical purposes, this distance may range up to six feet. The World Health Organization uses “approximately one meter”; the U.S. Occupational Safety and Health Administration uses “within six feet.” For consistency with these estimates, this document defines close contact as a distance of up to six feet.

*** SUNDAY, APRIL 26, 2009 ***

From Wilma Wooten, MD, MPH, Public Health Officer, County of San Diego: Swine Flu Update

Commentary from Dr. Wooten on the swine flu situation: “San Diego Public Health is approaching this situation very aggressively, as are federal and state governments. Please keep in mind that this situation is very dynamic and the situation changes rapidly. What we know today will change tomorrow; the guidelines that are disseminated today will change as the dynamics of the situation changes. As clinicians, we want certainty, but in this situation, we ask that you have “tolerance for uncertainty” and allow for a healthy a balance between prescription and permissiveness.”

What We Know:

• As of today, Sunday, April 26 at 3:00 p.m., there are 20 confirmed cases in five states in the United States: seven in California (four San Diego, three Imperial County), two in Texas, two in Kansas, eight in New York, and one in Ohio).
• The virus is spreading from person to person.
• We are now in the mitigation (trying to slow or decrease the spread) as opposed to the containment (trying to inhibit the spread as was the case last year with the San Diego measles outbreak) phase.

What We Want Healthcare Providers to Do:

• Based on the guidelines from CDC, anyone in San Diego seen by a provider with an influenza-like illness (ILI) and acute respiratory illness (ARI) (see definitions below) would require testing.
• Understand the new case definition as of today, at excerpted below.
• By virtue of the fact that San Diego has reported cases, everyone living in San Diego has essentially traveled to a location where there are confirmed cases.
• Obtain a specimen from the nasopharyngeal with a Dacron swab and send to the County Public Health Laboratory.

Definitions of Acute Respiratory Illness (ARI)

Recent onset of at least two of the following:

• rhinorrhea or nasal congestion
• sore throat
• cough
• fever or feverishness

Definition of Influenza-like illness (ILI)

• fever >37.8°C (100°F) plus cough or sore throat

Case Definitions for Infection With Swine Influenza A (H1N1) Virus

• A Confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness (ARI) with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests:
  • real-time RT-PCR
  • viral culture
  • four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies
• A Probable case of swine influenza A (H1N1) virus infection is defined as a person with an ARI with an influenza test that is positive for influenza A, but H1 and H3 negative.
• A Suspected case of swine influenza A (H1N1) virus infection is defined as:
  • A person with an ARI who was a close contact to a confirmed case of swine influenza A (H1N1) virus infection while the case was ill OR
  • A person with an ARI with a recent history of contact with an animal with confirmed or suspected swine influenza A (H1N1) virus infection OR
  • A person with an ARI who has traveled to an area where there are confirmed cases of swine influenza A (H1N1) within 7 days of suspect case's illness onset.
• The Infectious period for confirmed cases = 1 day before onset to 7 days after onset of illness_

What We Want You to Tell Your Patients:

• Stay home if you are sick; do not go to work, school, or travel.
• Confer with medical provider to determine if you need to be seen.
• See the CDC guidelines for homecare.

References:

• Interim Guidance for Antivirals
• Interim Recommendations for Masks
• Infection Control
• Cover Your Cough Posters

To contact San Diego Public Health or to report cases of public health importance, please contact County of San Diego, Health and Human Services Agency, Community Epidemiology Branch:

• Phone: (619) 515-6620
• Fax: (619) 515-6644
• Urgent Phone for evenings/weekends/holidays: (858) 565-5255
• Email
• Website

To sign up for electronic updates directly from San Diego County Health and Human Services Agency, click here.

*** SUNDAY, APRIL 26, 2009 ***

From the San Diego County Public Health Department: Swine Flu Update

No new swine flu cases reported in San Diego Cocunty.

The County of San Diego Health and Human Services Agency (HHSA) has no new cases of swine influenza to report today.

“The national declaration of a Public Health Emergency now allows us to utilize federal resources that are made available,” said Wilma Wooten, MD, MPH, County Public Health Officer. “It does not change anything that we are currently doing at the local level.”

HHSA continues to work closely with the Imperial County Public Health Department, the California Department of Public Health, and the Centers for Disease Control and Prevention to determine the cause of the infections and the extent of human-to-human spread. If additional cases are detected, HHSA will promptly report them to the public.

“We continue to have heightened surveillance and this will most likely increase our number of confirmed cases of human infection with swine influenza,” said Wooten. “Our advice to the public continues to be urging them to follow typical precautions they would follow during a regular flu season. Those include if you are sick, do not go to work, school, or travel. Cover your mouth when coughing, sneezing or blowing your nose, and wash your hands frequently.”

To date, four cases of swine flu have been reported in San Diego County. They are:

• A 10-year-old male (4/21/09)
• A 54-year-old male and his 16-year-old daughter (4/23/09)
• A 7-year-old male (4/24/09)

All four San Diego cases have recovered.

For additional information on swine influenza, visit the CDC website, the County of San Diego website, or call the County of San Diego Swine Influenza Information Line at (858) 715-2250.

*** SATURDAY, APRIL 25, 2009 ***

From the San Diego County Public Health Department: Swine Flu Update

No new swine flu cases reported in San Diego County.

The County of San Diego Health and Human Services Agency (HHSA) has no new cases of swine influenza to report today. Also, there are no pending suspected cases in San Diego County at this time.

HHSA is working closely with the Centers for Disease Control and Prevention and the California Department of Public Health to determine the cause of the infections and the extent of human-to-human spread. If additional cases are detected, HHSA will promptly report them to the public.

“We have heightened our surveillance and put area healthcare providers on alert. This will most likely generate additional cases of human infection with swine influenza,” said Wilma Wooten, MD, MPH, County Public Health Officer.

To date, four cases of swine flu have been reported in San Diego County. They are:

• A 10-year-old male (4/21/09)
• A 54-year-old male and his 16-year-old daughter (4/23/09)
• A 7-year-old male (4/24/09)

All four San Diego cases have recovered. Nationwide, the total number of cases of human infection stands at eight.

The public is being advised to follow typical precautions as they should during a regular flu season.

“If you are sick, do not go to work, school or travel. Cover your mouth when coughing, sneezing or blowing your nose, and wash your hands frequently,” Wooten concluded.

For additional information on swine influenza, visit the CDC's website, San Diego County's HHSA website, or call the County of San Diego Swine Influenza Information Line at (858) 715-2250.

*** FRIDAY, APRIL 24, 2009 ***

From the San Diego County Public Health Department: Swine Flu Update

The Health and Human Services Agency will continue its investigation on swine flu in San Diego County through the weekend and will be sending daily updates before noon.

*** THURSDAY, APRIL 23, 2009 ***

From the San Diego County Public Health Department: Swine Flu Update

On Thursday, April 23, 2009, the Centers for Disease Control and Prevention (CDC) announced that there are now seven confirmed cases of swine influenza A (H1N1) in the United States. Among these, three cases are from San Diego County. One of these cases was previously reported through EMAN as a 10-year-old. The two updated San Diego County cases are paternally related and include a 16-year-old and 54-year-old. All cases have recovered. Case and contact investigation by public health officials is underway. As of April 23, 2009, no epidemiologic link between any of the U.S. cases has been identified. All cases are closely related to each other genetically and represent a novel swine influenza virus not previously reported among swine or human influenza viruses in the United States or elsewhere. At least two patients demonstrated antiviral resistance to amantidine and rimantidine, but additional testing is underway to confirm apparent susceptibility to the neuraminidase inhibitor drugs oseltamivir and zanamivir. Seasonal influenza vaccine for the 2008–09 influenza season does not offer protection against swine influenza A (H1N1).

Swine influenza is an endemic disease in pigs but has caused sporadic illness in humans. A total of 12 human cases have been reported since 2005 in the United States, with none reported in California in the recent past. All patients recovered, and most had direct or indirect exposure to swine. Human-to-human transmission is rare, but all cases should be closely investigated to ensure human-to-human transmission is not occurring.

Although surveillance data from San Diego County for March and April indicates declining influenza activity, San Diego County clinicians are asked to follow the guidelines below when treating inpatients and outpatients with influenza-like illness [(ILI) Temperature >100ºF, and cough and/or sore throat]:

• For patients with positive influenza detections, please collect nasopharyngeal or throat swabs using personal protection equipment. All specimens should be placed in viral transport media and submitted to the San Diego County Public Health Laboratory. This includes cases of severe pediatric influenza.
• Influenza sentinel surveillance providers and emergency room clinicians should continue to perform routine clinical testing on patients presenting with ILI. Positive influenza results should be reported to the Community Epidemiology Branch using the Confidential Morbidity Report. Fax to (619) 515-6644. The Confidential Morbidity Report form may be found here.
• Cases of suspect animal influenza infection should be promptly reported to the Community Epidemiology Branch (CEB) at (619) 515-6620. After hours, page CEB on-call staff at (858) 565-5255.
• Infection control, treatment and chemoprophylaxis guidelines specific to swine influenza can be found at this CDC website.

“Interim Guidance on Infection Control and Antiviral Recommendations for Patients With Confirmed or Suspected Swine Influenza A Virus Infection”

BACKGROUND

Sporadic swine influenza A virus (SIV) infection of humans may produce a wide range of clinical signs and symptoms. Many human cases of SIV infection have had a history of recent direct physical contact with pigs prior to illness onset. However, close (within six feet) but not direct contact with pigs also has been reported among human SIV cases. Limited, non-sustained, human-to-human SIV transmission has been documented in the published literature. In addition, some confirmed SIV cases have not had a history of exposure to pigs.

Although uncomplicated influenza-like illness (fever, cough, or sore throat) has been reported in many cases, mild respiratory illness (nasal congestion, rhinorrhea) without fever and occasional severe disease also has been reported. Other symptoms reported with SIV infection include vomiting, diarrhea, myalgia, headache, chills, fatigue, and dyspnea. Conjunctivitis is rare, but has been reported. Severe disease (pneumonia, respiratory failure) and fatal outcomes have been reported with SIV infection. The potential for exacerbation of underlying chronic medical conditions or invasive bacterial infection with SIV infection should be considered.

This document provides interim guidance on infection control, antiviral treatment and chemoprophylaxis, and monitoring of close contacts of cases of swine influenza virus infection, including guidance for healthcare workers and public health personnel. The guidance will be updated as needed.

INTERIM RECOMMENDATIONS

For clinical care or collection of respiratory specimens from a symptomatic individual (acute respiratory symptoms with or without fever) who is a confirmed case, or a suspected case (ill close contact of a confirmed case) of swine influenza A virus infection:

Infectious Period

Persons with swine influenza virus infection should be considered potentially contagious for up to seven days following illness onset. Persons who continue to be ill longer than seven days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might potentially be contagious for longer periods. The duration of infectiousness might vary by SIV strain.

Case Definitions

A confirmed case of swine influenza virus infection (SIV) is defined as a person with an acute respiratory illness with laboratory confirmed SIV at CDC by one or more of the following tests:

1. real-time RT-PCR
2. viral culture
3. four-fold rise in SIV specific neutralizing antibodies

A suspected case of SIV is defined as a person with an acute respiratory illness who was a close contact to a confirmed case of SIV infection while the case was ill, or is an acutely ill person (acute respiratory illness) with a recent history of contact with an animal with confirmed or suspected SIV infection.

Close contact is defined as: within about six feet of an ill person who is a confirmed case of swine influenza A virus infection

Acute respiratory illness is defined as recent onset of at least two of the following: rhinorrhea or nasal congestion, sore throat, cough (with or without fever or feverishness)

RECOMMENDATIONS FOR PUBLIC HEALTH PERSONNEL

For interviews of healthy individuals (i.e., without a current respiratory illness), including close contacts of cases of confirmed swine influenza virus infection, no personal protective equipment or antiviral chemoprophylaxis is needed. See section on antiviral chemoprophylaxis for further guidance.

For interviews of an ill, suspected or confirmed SIV case, the following is recommended:

1. Keep a distance of at least six feet from the ill person; or
2. Personal protective equipment: fit-tested N95 respirator [if unavailable, wear a medical (surgical mask)].

For collecting respiratory specimens from an ill confirmed or suspected SIV case, the following is recommended:

1. Personal protective equipment: fit-tested disposable N95 respirator [if unavailable, wear a medical (surgical mask)], disposable gloves, gown, and goggles.
2. When completed, place all PPE in a biohazard bag for appropriate disposal.
3. Wash hands thoroughly with soap and water or alcohol-based hand gel.

Infection Control

Recommended Infection Control for a non-hospitalized patient (ER, clinic or home visit):

1. Separation from others in single room if available until asymptomatic. If the ill person needs to move to another part of the house, they should wear a mask. The ill person should be encouraged to wash hands frequently and follow respiratory hygiene practices.Cups and other utensils used by the ill person should be thoroughly washed with soap and water before use by other persons.

Recommended Infection Control for a hospitalized patient:

1. Standard, Droplet and Contact precautions for seven days after illness onset or until symptoms have resolved.
2. In addition, personnel should wear N95 respirators when entering the patient room.
3. Use an airborne infection isolation room (AIIR) with negative pressure air handling, if available; otherwise use a single patient room with the door kept closed.
4. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling.

Recommended PPE for personnel providing clinical care to ill individuals:

1. Disposable gown, gloves, goggles, N95 respirator.

Antiviral Treatment

Antiviral treatment for confirmed or suspected ill case of swine influenza virus infection may include either oseltamivir or zanamavir, with no preference given at this time. Recommendations for use of antivirals may change as data on antiviral susceptibilities become available.

Initiate treatment as soon as possible after the onset of symptoms.

Oseltamivir:

1. The treatment dosing recommendation for children who weigh 15 kg or less is 30 mg twice a day. For children who weigh more than 15 kg and up to 23 kg, the dose is 45 mg twice a day. For children who weigh more than 23 kg and up to 40 kg, the dose is 60 mg twice a day. For children who weigh more than 40 kg, the dose is 75 mg twice a day.
2. For ages 13 years and older: 75mg twice a day for five days

Zanamivir is an alternative for treatment of influenza in patients aged 7 years and older; dosage varies by age. This drug is not approved for treatment of influenza in children aged <7 years. It is an orally inhaled drug that is administered using a disk inhaler device twice a day for five days.

1. The treatment dosing recommendation for persons aged 7 years and older is 2 inhalations twice a day for five days (2 inhalations of 5mg each twice a day for five days)

Antiviral Chemoprophylaxis

Antiviral chemoprophylaxis (pre-exposure or post-exposure) can be considered for close contacts of a confirmed or highly suspected case of swine influenza virus infection.

Close contact is defined as: within about 6 feet of an ill person who is a confirmed case of swine influenza A virus infection (e.g. post-exposure chemoprophylaxis following unprotected close exposure).

Duration of antiviral chemoprophylaxis is 7 days after the last known exposure

Oseltamivir: Administered by mouth once a day for seven days following the last known exposure; dosage varies by age and weight for children aged 1 year to 12 years (available in suspension, 30mg, 45mg, 75mg capsules)

1. The chemoprophylaxis dosing recommendation for children who weigh less than 15 kg is 30 mg once a day. For those who weigh more than 15 kg and up to 23 kg, the dose is 45 mg once a day. For children who weigh more than 23 kg and up to 40 kg, the dose is 60 mg once a day. For children who weigh more than 40 kg, the dose is 75 mg once a day.
2. For ages 13 years and older: 75 mg once a day for seven days

Zanamivir is an alternative for chemoprophylaxis for patients aged 5 years and older; dosage varies by age. It is an orally inhaled drug that is administered using a disk inhaler device.

1. Dosing is 2 oral inhalations once a day for seven days (2 inhalations of 5mg each once a day for seven days)

Follow-up Monitoring of Exposed Close Contacts

Close contacts are defined as persons who were within about 6 feet of the confirmed swine influenza case while the case was ill up to 7 days after the case’s illness onset. Examples include household members, social contacts, public health care workers, medical health care workers, and others.

1. Close contacts should be monitored daily for fever (temp ≥38.0 ºC) and/or any respiratory symptoms up to 7 days following the last known exposure to an ill person who is a confirmed case of swine influenza virus infection.
2. Close contacts of an ill person who is a confirmed case of swine influenza virus infection should be educated about the signs and symptoms of swine influenza virus infection and advised to contact public health staff if fever or feverishness or any respiratory tract symptoms occur up to 7 days following the last known exposure to the ill case.

State and local health departments should contact CDC Influenza Division Epidemiology and Prevention Branch at (404) 639-3747 (Monday – Friday, 8:30 AM - 5:00 PM or the on-call epidemiologist at (770) 488-7100 (all other times).