To: Attending Medical Staff

From:
Michael Musicant, M.D., Chief of Staff
Gonzalo Ballon-Landa, M.D., Medical Director, Infection Prevention

Date: April 28, 2009

Subject: Swine Influenza

Background: As of April 27, 2009, the CDC has confirmed 20 cases of influenza-like illness caused by a novel swine influenza virus (influenza A:H1N1, a triple recombinant virus with gene segments of human, swine, and avian origin) in the U.S., occurring in San Diego County [4 cases], Imperial County [3], Texas [2], Kansas [2], Ohio [1] and New York City [28]. Since the patients had no reported exposure to pigs, there is a strong likelihood of person-to-person transmission; however, the efficiency of transmission is unknown. The CDC updates its website several times daily at http://www.cdc.gov/swineflu

The World Health Organization (WHO) is investigating more than 800 cases in Mexico with more than 80 fatalities since March 2009. Very preliminary investigation suggests that the H1N1 strain in the U.S. is identical to the strain from Mexico. Canada has just confirmed 6 cases of swine flu. The WHO director, Dr. Margaret Chan, said the new strain of H1N1 has the potential to become a pandemic strain because it does spread easily and does cause serious disease. At least in the United States, it has so far only been found in people who had mild illness, another factor that would have allowed it to spread undetected. (Thomson Reuters, 4.26.09)

Case Definition: Clinicians caring for San Diego County and Imperial county residents who present with febrile (>100.4°F) respiratory illness (cough, sore throat, rhinorrhea, nasal congestion, myalgias, diarrhea, etc) should have swine influenza in their differential (suspected cases). A confirmed case requires CDC verification of swine influenza A:H1N1. Inquire about visits to Mexico, Kansas and Guadalupe County, Texas 7 days prior to onset of symptoms.

Diagnostic Testing: Please obtain a nasopharyngeal swab for viral culture. CALL the microbiology lab (xt. 4492) and request a viral culture transport solution. Use the enclosed Q-tip and DO NOT USE culturettes. Since it is unknown whether the rapid tests for human influenza A:H1N1 will be equivalent for swine influenza A:H1N1, the rapid tests SHOULD NOT be used to screen for swine influenza. (You can elect to send a rapid screen, but the lab will need TWO specimens.)

Prevention of Transmission: http://www.cdc.gov/swineflu/guidelines_infection_contr ol.htm ·

Source control. Anyone presenting with a febrile respiratory illness should be offered a REGULAR, NOT AN N-95 MASK. Patients with suspected or confirmed swine flu be transported with a regular mask in place.

·Place signage in ED to alert triage in the event that a person is being seen for respiratory illness so that masks can be promptly provided for them. We may elect to cohort patients with respiratory symptoms in the ED.

·Keep your hands off your face.

·Practice hand hygiene consistently and instruct family/visitors to do the same.

·Encourage patients to "cover your cough" and provide tissues in ED with proper disposals. When tissues are not available, sneeze/cough into the upper sleeve, rather than into the hands.

·Minimize visitation, especially persons with respiratory tract infections.

·Patients with respiratory illnesses should be cared for in private rooms with doors closed or if available, airborne infection isolation rooms.

-For personnel providing direct patient care for suspected/confirmed swine influenza cases, wear an N95 mask or respirator, in addition to gloves, gowns, and eye protection (e.g., goggles) when entering the patient room and for aerosol generating activities (e.g., collection of clinical specimens (nasopharyngeal swabs), endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation). It is likely that precaution guidelines will be modified as the modes of transmission of swine flu are better defined.

·Patients are considered contagious beginning 1 day before the onset of symptoms and continuing for 7 days after the onset of illness, or until symptoms resolve.

·Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza.

Treatment: Laboratory studies indicate susceptibility to neuraminidase inhibitors [oseltamivir phosphate (Tamiflu), zanamivir (Relenza)] but resistance to the adamantanes (amantadine (Symmetrel), rimantidine (Flumadine). See http://www.cdc.gov/swineflu/recommendations.htm

We will update our Medical Staff as more data become available. For questions, please email: michael.musicant@sharp.com or shauna.tarrac@sharp.com.

Thank you and we urge that you adhere to the principles of infection prevention during this period of discovery. During the SARS outbreak in Hong Kong, knowledge of and adherence to infection prevention principles were protective for healthcare providers.

We are discussing restrictions on visitors to the hospital, more widespread availability of hand gels in the hospital, advice and protocols for our Physicians' office personnel and families, cooperation among all of our cities' hospitals and other matters. We have to walk a fine line between premature overreaction and failure to prepare for a possible true public health crisis.

Are you interested in seeing a recently published issue of the E-Bulletin?