Microsoft word - swine flu - health alert 4-28-09 _jlj_.doc

State of California—Health and Human Services Agency MARK B HORTON, MD, MSPH
ARNOLD SCHWARZENEGGER
SWINE INFLUENZA A (H1N1)
HEALTH ALERT
Current Situation
• As of today, 11 California residents in three counties (San Diego, Imperial and
Sacramento) have been diagnosed with confirmed swine influenza A (H1N1) virus infection; there are also currently four probable cases in these counties under investigation. All but two patients have had self-limited Influenza-like illness (ILI); two patients with underlying conditions were hospitalized. All have recovered. • Because there was a probable case in a Sacramento school with an epi-link to another possible case and evidence of other students with ILI, a decision was made to dismiss school until 7 days after the last day an infectious child attended school. • CDPH has drafted an interim policy on school dismissal and received input from local Health Officers in a conference call today. case of swine influenza A (H1N1) virus infection: a person with an acute respiratory illness with an influenza test that is positive for influenza A, but human H1 and H3 negative (i.e., unsubtypeable). illness: fever >37.8°C (100°F) and a cough and/or sore throat.
Influenza Surveillance Recommendations
Because of the rapidly evolving situation and in an attempt to focus laboratory
resources, revised enhanced surveillance guidance is being issued. At this time,
testing at public health laboratories should be focused on:
• Hospitalized patients with ILI
• Outpatients with ILI in the following categories:
o Patient is a contact of a confirmed swine influenza A (H1N1) case o Patient is in a high-risk setting for transmission (e.g., school, prison) California Department of Public Health, P.O. Box 997377, Sacramento, CA 95899-7377
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o Patient is part of a cluster of people with ILI (only one patient needs o Patient returned from Mexico within 7 days of illness onset or cared for ill household members with this travel history
Influenza sentinel surveillance providers should continue submitting
specimens according to protocol to the CDPH Viral and Rickettsial Disease Laboratory
(VRDL). Any influenza A non-subtypeable results will be reported to the LHD
immediately.
The CDPH VRDL will continue to support those LHDs that do not have access to PCR
testing for influenza as well as local public health laboratories that need assistance with
their testing as demand increases. Please alert VRDL if you are sending specimens
from patients in any of the above listed categories so testing can be prioritized (e-mail
cynthia.jean@cdph.ca.gov and david.cottam@cdph.ca.gov

Case and contact investigation
Case and contact report forms and laboratory report forms are posted on the CDPH
swine influenza website
at:http://www.cdph.ca.gov/HealthInfo/discond/Pages/SwineInfluenza.aspx

Laboratory Updates:
On a statewide call with laboratory directors it was decided that for Northern CA Kaiser
patients, specimens from suspect swine influenza cases will first be tested for Flu A at
Kaiser Regional Laboratory. Specimens that test positive for Flu A will be forwarded to
VRDL for sub-typing. For positive flu A cases, Kaiser will alert the patient’s public
health county of residence of positive test result.
VRDL has requested a large supply of swabs, viral transport media and shipping
boxes. We ask that the local public health laboratories contact us (by e-mailing
david.cottam@cdph.ca.go and tong.kong@cdph.ca.gov) with your anticipated supply
needs in the next 48 hours. We plan to be sending out those supplies to local public
health laboratories within the next few days. All requests from individual hospitals and
clinics for specimen collection supplies will be referred to the local health department for
assistance.
Commercial laboratories do not currently offer swine influenza testing. We are asking
that requests for swine influenza testing be triaged at the clinic or hospital laboratory in
the following way:

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Hospital Prioritization Scheme for Swine Influenza H1 (SwH1) Testing*
[rev. 04/27/09]
Triage requests for swine
influenza testing
HIGH-RISK
Patient is a contact of a confirmed swine influenza (Order Flu A)
Patient is part of a cluster of people with ILI (only one Patient returned from Mexico within 7 days of illness onset or cared for ill household * Priorities for testing will likely change
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Specimen collection and algorithm for testing in public health laboratories (See
attachments)
• Specimen
Please collect one to two respiratory samples (depending on specimen collection resources) from each patient with ILI. Nasopharyngeal swabs and nasal aspirates are preferable; throat swabs are acceptable if an NP swab or nasal aspirate cannot be obtained. The swabs should be placed 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. • Specimen storage: The specimens should be kept refrigerated at 4ºC and sent on cold packs if they can be received by a public health laboratory within five days of the collection date. If samples will be received by the laboratory in five or more days from collection, they should be frozen at -70 ºC or below and shipped on dry ice. o Viral transport media o Mask and gloves *Cotton or calcium alginate swabs are not acceptable. PCR assays may be inhibited
by residues present in these materials
Procedure: 1. Put on mask and gloves. 2. Have patient sit with head against a wall as patients have a tendency to pull 3. Insert swab into one nostril straight back (not upwards) and continue along the
floor of the nasal passage for several centimeters until reaching the nasopharynx (resistance will be met). The distance from the nose to the ear gives an estimate of the distance the swab should be inserted. Do not force swab, if obstruction is encountered before reaching the nasopharynx, remove swab and try the other side. 4. Rotate the swab gently for 5-10 seconds to loosen the epithelial cells. 5. Remove swab and immediately inoculate viral transport media by inserting the swab at least ½ inch below the surface of the media. Bend or clip the wire swab handle to fit the transport medium tube and reattach the cap securely. A dry swab is not acceptable for PCR testing.
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6. Specimen should be transported at refrigerator temperature and received by laboratory as soon as possible and <3 days from time of collection. For a video of NP swab collection, please see: http://video.cdc.gov/asxgen/nip/isd/swabdemo.wmv

Infection Control Precautions
CDPH concurs with CDC’s “Interim Guidance for Infection Control for Care of Patients
with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare
Setting,” April 24, 2009, which can be accessed at:
http://www.cdc.gov/swineflu/guidelines_infection_control.htm
Recommendations for antiviral therapy and prophylaxis for swine influenza A
(H1N1)
These recommendations are subject to change based on current conditions
CDPH concurs with the Center for Disease Control and Prevention’s (CDC’s) current
“Interim Guidance on Antiviral Recommendations for Patients with Confirmed or
Suspected Swine Influenza A (H1N1) Virus Infection and Close Contacts,” which can be
accessed at:
http://www.cdc.gov/swineflu/recommendations.htm
This guidance refers to the current recommended daily dosage of influenza antiviral
medications for treatment and chemoprophylaxis.
Higher doses of oseltamivir (e.g., 150 milligrams twice daily) may be considered on a
case-by-case basis in severe swine influenza A (H1N1) infections, particularly if there is
pneumonic disease at presentation or evidence of clinical progression. There is

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currently no evidence for enhanced efficacy of high-dose oseltamivir therapy in swine A
(H1N1) infections, but this recommendation aligns with World Health Organization
Advice for Avian Influenza A (H5N1) infections. High-dose therapy appears to offer no
additional benefit for the treatment of seasonal influenza.
Other CDC Guidance Documents
Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home, April 25, 2009. http://www.cdc.gov/swineflu/guidance_homecare.htm Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been Detected, April 26, 2009. http://www.cdc.gov/swineflu/masks.htm Swine Influenza A (H1N1) Virus Biosafety Guidelines for Laboratory Workers, April 24, 2009. http://www.cdc.gov/swineflu/guidelines_labworkers.htm Community Strategy for Pandemic Influenza Mitigation February 2007 http://www.pandemicflu.gov/plan/community/commitigation.html
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Source: http://www.ci.garden-grove.ca.us/pdf/h1n1-alert.pdf