CDC Web Site: http://www.cdc.gov/swineflu/

News from Tom Gehring
Executive Director/CEO
San Diego County Medical Society

As of 5 pm today (Monday), there are 5 confirmed cases of human swine influenza A (H1N1) infection in San Diego County. A local press release and video is available at: http://www.sdcounty.ca.gov/Portal/News/swineflu.html .

According to 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 e-mail updates regarding case count and investigation updates from the CDC, go to the following website: http://www.cdc.gov/swineflu/investigation.htm [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 at: http://www.who.int/csr/disease/avian_influenza/phase/ en/index.html

Antiviral dosing
If antivirals are indicated, go to the following website for details on antiviral dosing: http://www.cdc.gov/flu/professionals/antivirals/dosaget able.htm#table

Here are some questions & answers from Monday, as well as some constructive suggestions. We are in a fluid environment, so today's answers may be superseded as more news is available.

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 health care 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 CDC's Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home at http://www.cdc.gov/swineflu/guidance_homecare.htm

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 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 CDC's Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home at http://www.cdc.gov/swineflu/guidance_homecare.htm

Frequently Asked Questions and Answers

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 that if 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 - Here is the form to be attached to the NP sample, along with sampling instructions: http://www.cdph.ca.gov/programs/vrdl/Documents/Swin e_Influenza_Surveillance_Specimen_Submittal_Form _42709.pdf . Here are the instructions for NP testing: http://www.cdph.ca.gov/programs/vrdl/Pages/Testingfor SwineInfluenzaA(H1N1).aspx.

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 pickup. 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.

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 & Human Services Agency, go to http://www.co.san- diego.ca.us/hhsa/programs/phs/eman/subscribe.html

CDC Guidance for Facemask and Respirator Use: Here are the Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been Detected: http://www.cdc.gov/swineflu/masks.htm, excerpted below

Information on the effectiveness of facemasks(1)and respirators(2) 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(3) 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 at www.cdc.gov/swineflu.

When crowded settings or close contact with others cannot be avoided, the use of facemasks1 or respirators2 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(1) 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(2) 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.

Footnotes

1 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.

2 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).

3 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 6 feet. The World Health Organization uses "approximately 1 meter"; the U.S. Occupational Safety and Health Administration uses "within 6 feet." For consistency with these estimates, this document defines close contact as a distance of up to 6 feet.

Tom Gehring, Executive Director/CEO
San Diego County Medical Society
5575 Ruffin Road, Suite 250, San Diego, CA 92123
T: (858) 565-8597 (desk)
T: (619) 206-8282 (cell)
F: (858) 569-1334
E: gehring@sdcms.org

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