Texas Guidance for Clinicians: Patients with Influenza-Like Illness

From the Texas Department of State Health Services:

Update:
Texas has confirmed cases of swine flu.  The original two confirmed cases of swine flu have recovered. Additionally, cases of novel swine flu have been identified in California, Kansas and in Mexico.  The characterization of the virus in Mexico shows it is the same as the swine flu virus in the Texas cases.  CDC epidemiologists have been deployed to Texas, Mexico, and California. Suspected cases are being investigated in other states.

Clinicians throughout Texas should enhance surveillance of patients who present with illness consistent with influenza disease and no alternate explanation for the illness.  This is especially important since fewer cases of influenza are presenting at this time.

Unless there is evidence to the contrary, swine influenza should be highly suspected in persons with influenza-like illness.

Laboratory Testing Protocol for Persons with Influenza-Like Illness or Acute Respiratory Illness:
1.  Perform influenza testing on all patients with influenza-like illness (ILI:  fever >100° F and cough and/or sore throat)

2.  Perform influenza testing on all patients with acute respiratory illness (ARI:  recent onset of at least two of the following:  rhinorrhea or nasal congestion, sore throat, cough (with or without fever or chills)   and

• a history of recent travel to Mexico (within 7 days) or
• contact with a person who has been diagnosed with Influenza A.

Perform rapid flu testing, if available, for immediate decisions regarding communicability.  However, rapid flu testing is not sufficiently sensitive to rule out influenza.   Regardless of results of rapid flu testing, collect and submit specimen (see acceptable specimens below) for viral culture.

Submit all specimens to the Department of State Health Services or the appropriate public health department laboratory even if viral culture specimens are routinely submitted to another laboratory.  Collection and submission instructions are below.

Specimen Collection Guidelines for Influenza Specimens

Respiratory Specimens

Acceptable specimens for influenza testing include a nasopharyngeal or throat swab, nasal wash, or nasal aspirates. Preferred specimen is a combination throat/nasal pharyngeal swab or oral pharyngeal swab or nasal wash. Other routine respiratory specimens, such as a bronchial wash, or sputum will be acceptable.

Samples should be collected within the first 4 days of illness. Swabs used for specimen collection should have a Dacron tip and an aluminum or plastic shaft. Swabs with calcium alginate or cotton tips and wooden shafts are not recommended, as these have substances that can interfere with PCR procedure. Specimens should be put into an approved biohazard bag and placed at 4°C immediately after collection.

Procedure	Influenza Types Detected	Acceptable Specimens	Transport
RT-PCR	A and B	Nasopharyngeal swab, throat swab, nasal wash, bronchial wash, nasal aspirate, sputum	Cold on Ice Packs –or- Frozen on Dry Ice. Submit same day as collection

Transport cold on ice packs or freeze at – 70° C and ship on dry ice.  Although specimens are acceptable for culture within 4 days of collection, due to the current situation, please submit specimens the same day as collected.

When influenza A is detected in your clinic by rapid testing methods, please send an aliquot (1-2 ml) of the original suspension (not exposed to test kit reagents) in viral transport media or equal; or if an additional original specimen swab in viral transport media is available, that is preferable.

FDA authorizes emergency use of influenza medications, diagnostic tests in response to swine flu outbreak

From MPR:

The FDA, in response to requests from the CDC, has issued Emergency Use Authorizations (EUAs) to make diagnostic and therapeutic tools, including the rRT-PCR Swine Flu Panel and Tamiflu (oseltamivir, from Roche) and Relenza (zanamivir, from GlaxoSmithKline) antiviral products, available to public health and medical workers to identify and respond to the swine flu virus under certain circumstances. The EUA authority also allows the FDA to authorize the use of unapproved drugs or unapproved uses of approved drugs following a determination and declaration of emergency, provided certain criteria are met. The authorization will end when the declaration of emergency is terminated or authorization revoked by the FDA.

Tamiflu is indicated for the treatment of uncomplicated acute illness due to influenza infection in patients ≥1year of age who have been symptomatic for ≤2days and prophylaxis of influenza in patients ≥1year of age. The EUA will allow Tamiflu to be used for the treatment and prevention of influenza in children <1year of age and provide alternate dosing recommendations for children >1year of age.

Relenza is indicated for the treatment of uncomplicated acute illness due to influenza A and B virus in patients ≥7years of age who have been symptomatic for ≤2days and the prophylaxis of influenza in patients ≥5 years of age. Under the EUA, both Tamiflu and Relenza may be distributed to large segments of the population, without complying with the label requirements, and with written information pertaining to the emergency use. They may also be distributed by a broader range of healthcare workers, including some public health officials and volunteers, in accordance with applicable state and local laws and/or public health emergency responses.

WSJ Live Blog: WHO Swine Flu Update

From the Wall Street Journal Health Blog:

Excerpts:

Margaret Chan, WHO Director-General, is giving an update on the swine flu. Here’s what she’s saying.

4:07 WHO is raising the pandemic alert level from Phase 4 to Phase 5. Phase 5 means a pandemic is imminent. (See an explanation of the WHO’s pandemic-alert levels.)

4:10 “All countries should immediately now activate their pandemic preparedness plans,” remain on alert for pneumonia and influenza-like illness.

4:21 Level five of the pandemic alert requires human-to-human transmission in a sustainable manner that is causing community-level spread in more than one country. We are seeing that in Mexico and the U.S. When we see two countries in one WHO region demonstrating that, we are moving into Phase 5.

Another Swine Flu Outbreak Map

From Google:

This is a map depicting confirmed and suspected cases of the 2009 H1N1 outbreak, with contributors from all over the world, from a variety of backgrounds (health, journalism, technology).

Click on the first link below to see the map legend.

We are striving to keep this map as accurate as possible. If you’d like to help out, please leave a comment on the “comments” page, with a link to your source of information, and we will strive to update the map as soon as possible. Thank you!

Link to this map: http://tinyurl.com/swinemap09

For more on Swine Flu (H1N1): http://www.cdc.gov/swineflu/

Emergency Physicians Monthly Swine Flu Resource

From Emergency Physicians Monthly:

What every emergency physician needs to know about swine flu today*

By Amesh Adalja, MD

*This article is adapted from the author’s earlier report in the Clinician’s Biosecurity Network, available at http://www.upmc-cbn.org/report_archive/2009/04_April_2009/04-09_Swine_Flu_2009/cbnreport_SF1_4-24-09_AM.html

On April 21, 2009, the Centers for Disease Control and Prevention (CDC) issued an MMWR Dispatch describing 2 cases of swine influenza A (H1N1) infection that occurred in Southern California in April. While both patients recovered uneventfully, the isolated viruses harbor novel genetic characteristics not seen in swine flu isolates in the U.S. prior to this event. The other striking feature of these cases is that there was no known contact with swine, raising the question of efficient human-to-human transmission of this virus [1] Subsequent investigation has uncovered 40 additional cases in the United States—all of whom have recovered uneventfully—and reports of severe morbidity and mortality in Mexico. Several other countries including Canada, Scotland, and Spain are reporting confirmed cases.

Why the Emergency Physician Should Know about Swine Flu

As with all emerging infectious diseases, emergency physicians are likely to find themselves on the front line contronting swine flu. It is vital that they be informed with the best information when confronting this potentially deadly virus.

CDC: Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting

From the Centers for Disease Control and Prevention:

Infection Control of Ill Persons in a Healthcare Setting

Patients with suspected or confirmed case-status should be placed in a single-patient room with the door kept closed. If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling.

The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. More information can be found at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.

Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Maintain adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions.

Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure.

Masks and respirators: Until additional, specific information is available regarding the behavior of this swine influenza A (H1N1), the guidance in the October 2006 “Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic” http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.html should be used. These interim recommendations will be updated as additional information becomes available.

Interim recommendations:

• Personnel engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator.*
• Pending clarification of transmission patterns for this virus, personnel providing direct patient care for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator when entering the patient room.

*Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Information on respiratory protection programs and fit test procedures can be accessed at http://www.osha.gov/SLTC/etools/respiratory. Staff should be medically cleared, fit-tested, and trained for respirator use, including: proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use.

Additional information on N95 respirators and other types of respirators may be found at: http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html, and at www.fda.gov/cdrh/ppe/masksrespirators.html

CDC Releases Swine Flu Guidelines for Clinicians

From the Centers for Disease Control and Prevention:

Clinicians

Clinicians should consider the possibility of swine influenza virus infections in patients presenting with febrile respiratory illness.

If swine flu is suspected, clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.

The WSJ Health Blog on Swine Flu

The Wall Street Journal is serving the public with insight and context on the Swine Flu threat

Live blogging from the CDC teleconference

Excerpt:  The WHO’s Keiji Fukuda is talking to reporters about the current swine flu situation. Here’s what he’s saying.

11:10: There have been 79 laboratory confirmed infections. Forty from U.S., 26 from Mexico, six from Canada, two from Spain, two from the U.K. and three from New Zealand. The WHO is reporting seven laboratory-confirmed deaths, all in Mexico. That’s a lower figure for deaths than others have reported.

11:15 It’s unclear whether this will turn into a pandemic. But countries should prepare for that possibility.

“A Century of Flu Pandemics”

Excerpt: Flu is a quickly mutating virus that infects birds, pigs and humans. So it’s only natural that, every so often, a new strain emerges from the animal world and starts passing from person to person.

These strains vary widely in the severity of disease they cause and in the ease with which they pass from person to person. Those variables aren’t yet clear in the case of swine influenza A (H1N1), the new strain of swine flu — and they may change over time, as the virus continues to mutate.

Looking back at flu outbreaks from the 20th century gives some sense of the range of possible outcomes.

There was the Spanish Flu of 1918, which this historical overview from the feds calls “the catastrophe against which all modern pandemics are measured.” Some 30% of the world’s inhabitants fell ill; there were an estimated 500,000 deaths in the U.S. alone.

ACEP Proxy System Coding

From Modern Healthcare:

HCA, Nashville, said using an emergency department coding procedure developed by the American College of Emergency Physicians boosted its operating earnings by $75 million to $100 million in the first quarter ended March 31. The company also said that its readmission rates compare favorably with those reported in a recent study in the New England Journal of Medicine.

HCA said that it earned $360 million, up from $170 million in 2008’s first quarter. Revenue increased 4.3% to $7.43 billion. Admissions declined 0.9% but equivalent admissions increased 1.9% when comparing the quarters on a same-facility basis in each case.

HCA began studying the use of the new coding procedure after the CMS said a so-called proxy system, such as the ACEP’s, would comply with Medicare regulations, said Milton Johnson, executive vice president and chief financial officer. The system, which HCA implemented fully by the end of 2008, greatly simplifies the coding procedure, Johnson said. Financial results of the coding system could vary in future quarters, Johnson added.

Jonathan Perlin, chief medical officer and senior vice president of quality, said that HCA’s Medicare readmission rates are much lower than the 19.6% of readmissions within 30 days of discharge reported in the journal study.

Swine Flu: Live Blogging CDC’s Monday Conference Call

Good stuff from the WSJ Health Blog:

an excerpt:

The WHO said earlier today that there have been 40 cases of swine flu confirmed in the U.S. So far, cases in this country appear to have been mild, but officials have warned that more severe cases could emerge. Richard Besser, acting head of the CDC, is providing an update to reporters this afternoon. Here’s what he’s saying.

1:09 There have been 40 confirmed U.S. cases in five states. The 20 newly confirmed cases are associated with the previously reported outbreak in a New York school. The new cases represent additional testing, not newly discovered cases.

1:10 No fatalities have been reported in the U.S.

1:12 The CDC recommends that people avoid non-essential travel to Mexico. “This is out of an abundance of caution,” Besser says.