Health & Human Services Agency Public Health Division 2344 Old Sonoma Road Building G Napa, CA 94559 www.co.napa.ca.us/PublicHealth Main: (707) 253-4270 Fax: (707) 253-4880 Randolph F. Snowden Agency Director
HEALTH ALERT SWINE INFLUENZA ENHANCED SURVEILLANCE
April 28, 2009To: Napa County Clinicians and Healthcare Facilities: As part of an ongoing investigation into an outbreak of swine influenza A (H1N1) in the United States and Mexico, CDC today announced confirmation 64 human cases of infection with swine flu in the U.S. The California Department of Public Health (CDPH) is reporting 10 confirmed cases in California. There are additional probable cases undergoing final confirmatory testing in both California and other states. Based on the continued rapid spread of the virus thus far, public health officials believe that more cases will be identified over the next several weeks. There are no probable or confirmed cases in Napa County at this time. Because human to human transmission of this novel influenza virus is suspected to be ongoing in California, CDPH and the Centers for Disease Control and Prevention (CDC) are requesting enhanced influenza like illness (ILI) surveillance by the medical community statewide. This Alert is to provide you with information on when to suspect swine influenza, indications for submitting specimens to Napa Public Health for further testing, instructions for specimen submission, infection control guidance, current treatment recommendations and links to further information for clinicians and patients. Please be aware that the situation is evolving rapidly and these recommendations may change on an ongoing basis. The following are the CDC case definitions to be used for swine influenza: A confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests: 1. real-time RT-PCR 2. viral culture A probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute febrile respiratory illness who is: • positive for influenza A, but negative for H1 and H3 by influenza RT-PCR, or • positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case.
A suspected case of swine influenza A (H1N1) virus infection is defined as a person with acute febrile respiratory illness with onset • within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection, or • within 7 days of travel to a community either within the United States or internationally where there are one or more confirmed swine influenza A(H1N1) cases, or • resides in a community where there are one or more confirmed swine influenza cases. For current information on the distribution of swine influenza cases, visit: http://www.cdc.gov/swineflu/index.htm 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). In Napa priority will be given to testing specimens from probable and suspect cases for which the travel history is to Mexico. As resources permit we will also accept samples from suspect cases with travel to communities in the United States with confirmed cases of swine influenza A. Specimen collection Please collect up to 2 nasopharyngeal or throat swabs from each patient with ILI, placing the swabs in a standard container with 2-3 ml of viral transport media. If the patient is hospitalized with pneumonia, specimens from the lower respiratory tract (e.g., tracheal aspirate, bronchoalveolar lavage) should also be obtained. Specimens should be collected within the first 24-72 hours of onset of symptoms and no later than 5 days after onset of symptoms. Napa Public Health has a limited capacity for collection of samples from probable and suspect cases in the outpatient setting. If you do not have the capacity to collect specimens but feel the patient meets the criteria listed above, please call Napa Public Health Communicable Disease Control at (707) 2531499. To discuss submission of specimens directly, press 0. You may also leave a voicemail or send a fax with your name and office number and the patient’s name, birth date, address and phone number. Or you may complete a Confidential Morbidity Report form and fax to (707) 299-4479. Specimen storage The specimens should be kept refrigerated at 4ºC and sent on cold packs if they can be delivered to Napa County Public Health within three days of the collection date. If samples will be received by Public Health four or more days from collection, they should be frozen at -70 ºC or below and delivered on dry ice. Submission of specimens to the Napa Solano Public Health Laboratory Please complete the attached laboratory submission form for each specimen collected. When specimens are ready for submission to the PH Laboratory please deliver them with the accompanying submission forms to Napa County Public Health Monday through Thursday between 8 am and 5 pm at Building G, 2344 Old Sonoma Road in Napa. Please note that the building is closed between noon and 1 pm. Infection Control Precautions Healthcare workers providing care for patients with influenza-like illness who are not known contacts of a laboratory-confirmed swine flu case should use droplet precautions (i.e., wear a surgical or procedure mask for close contact), in addition to standard precautions. Standard precautions include
hand hygiene and the use of eye protection if splashing or spraying of blood or body fluids (including respiratory secretions) is anticipated.* Healthcare workers providing care for a laboratory-confirmed swine flu case or an ill close contact of a laboratory-confirmed swine flu case should: 1) Wear a fit-tested N95 respirator, disposable gloves, gown, and eye protection (face shield or goggles). 2) Before and after contact with the patient, clean hands thoroughly with soap and water or an alcohol-based hand gel. Suspect swine flu patients (ill close contact of a laboratory-confirmed swine flu case) should be asked to don a surgical mask and should be roomed promptly in an airborne infection isolation room, if available, or in a single room with a door that closes. *Splashing or spraying of body fluids may be anticipated when collecting a nasopharyngeal or throat swab. Current treatment recommendations All confirmed cases of swine influenza A in the United States to date have been mild with full recovery. In addition, seasonal influenza viruses including both influenza A and B continue to circulate in the community. Thus, the approach to treatment consideration for a patient suspected to have swine influenza A should be the same as that for any other patient with influenza. Empiric treatment should be prioritized for confirmed or probable swine influenza A cases. Priority should be given to hospitalized patients and patients at higher risk of influenza complications. This swine influenza A (H1N1) virus is sensitive (susceptible) to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir. It is resistant to the adamantane antiviral medications, amantadine and rimantadine. Recommendations for treatment regimes and for antiviral prophylaxis can be found at www.cdc.gov/swineflu/guidance/. In general, chemoprophylaxis is recommended only for persons at high risk for complications of influenza who are either travelers to Mexico or household contacts to a confirmed, probable or suspect swine influenza A case. Please do not hesitate to contact us at (707) 253-4231 if you have questions or concerns. Additional information is available at the following websites: Napa County Public Health: http://www.co.napa.ca.us/publichealth CDPH: http://www.cdph.ca.gov/HealthInfo/discond/Pages/SwineInfluenza.aspx CDC: http://www.cdc.gov/flu/swine/ (updated daily at 3:00 PM EDT) Regards,
Karen Smith, M.D., M.P.H. Public Health Officer Email: ksmith@co.napa.ca.us