CDC HAN Advisory & MMWR: HIV & HCV Among Injectable Drug Users

 

# 9974

 

Over the past month we’ve been following the HIV and HCV outbreak in Southeastern Indiana (see Indiana Gov To Declare HIV Health Emergency In Scott County & Scott County HIV Epidemic Reaches 130 Cases) which has now grown to 142 cases. 

 

Reportedly, at least 80% of these cases are injectable drug users, and this practice appears to be driving this epidemic.

 

Today the CDC, along with officials from the State of Indiana, held a 50-minute-long press conference in advance of the release of a CDC HAN  message, and an early release MMWR called  Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone — Indiana, 2015.

The MMWR describes socio-economic situation in Scott County as:

Injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together. IDU practices include crushing and cooking extended-release oxymorphone, most frequently 40 mg tablets not designed to resist crushing or dissolving. Syringes and drug preparation equipment are frequently shared (e.g., the drug is dissolved in nonsterile water and drawn up into an insulin syringe that is usually shared with others). The reported daily numbers of injections ranged from four to 15, with the reported number of injection partners ranging from one to six per injection event.

Like many other rural counties in the United States, the county has substantial unemployment (8.9%), a high proportion of adults who have not completed high school (21.3%), a substantial proportion of the population living in poverty (19%), and limited access to health care (1). This county consistently ranks among the lowest in the state for health indicators and life expectancy (2).

 

And the demographics of the outbreak:

 

The age range of the 135 patients is 18–57 years (mean = 35 years; median = 32 years); 74 (54.8%) are  male. A small number of pregnant women were diagnosed with HIV infection and started on antiretroviral  therapy during pregnancy. As of April 21, no infants had tested positive for HIV. Of the 135 persons with diagnosed HIV infection, 108 (80.0%) have reported injection drug use (IDU), four (3.0%) have reported no IDU, and 23 (17.0%) have not been interviewed to determine IDU status. Among the 108 who have reported IDU, all reported dissolving and injecting tablets of oxymorphone as their drug of choice. Some reported injecting other drugs, including methamphetamine and heroin. Ten (7.4%) female patients have been identified as commercial sex workers. Coinfection with hepatitis C virus has been diagnosed in 114 (84.4%) patients

 

Because the conditions described in Scott county are not necessarily unique to that part of the country, the CDC has issued a HAN Advisory to alert clinicians to be alert to signs of similar outbreaks in their communities, so that public health interventions can come sooner rather than later.

 

Some excerpts from a much longer HAN Advisory follow: 

 

Outbreak of Recent HIV and HCV Infections among Persons Who Inject Drugs

 This is an official CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network
April 24, 2015, 11:00 ET (11:00 AM ET)
CDCHAN-00377

Summary

The Indiana State Department of Health (ISDH) and the Centers for Disease Control and Prevention (CDC) are investigating a large outbreak of recent human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Many of the HIV-infected individuals in this outbreak are co-infected with hepatitis C virus (HCV). The purpose of this HAN Advisory is to alert public health departments and healthcare providers of the possibility of HIV outbreaks among PWID and to provide guidance to assist in the identification and prevention of such outbreaks.

<SNIP>

Recommendations for Health Departments

• Review the most recent sources of data on HIV diagnoses, HCV diagnoses (acute as well as past or present), overdose deaths, admissions for drug treatment, and drug arrests. Attributes of communities at risk for unrecognized clusters of HIV and HCV infection include the following:
  • Recent increases in the:
    • Number of HIV infections attributed to injection drug use,
    • Number of HCV infections, particularly among persons aged < 35 years;
  • High rates of injection drug use and especially prescription-type opioid abuse, drug-related overdose, drug treatment admission, or drug arrests.
• Ensure complete contact tracing for all new HIV diagnoses and testing of all contacts for HIV and HCV infection.
• Ensure persons actively injecting drugs or at high-risk of drug injection (e.g., participating in drug substitution programs, receiving substance abuse counseling or treatment, recently or currently incarcerated) have access to integrated prevention services,⁹ and specifically:
  • Are tested regularly for HIV and HCV infection (consider more frequent testing based on frequency of injection drug usage or sharing of injection equipment);
  • If diagnosed with HIV or HCV infection:
  • Are rapidly linked to care and treatment services;
  • If actively injecting drugs:
    • Have access to medication-assisted therapy (e.g., opioid substitution therapy) as well as other substance abuse services, if not already engaged,
    • Are counseled not to share needles and syringes or drug preparation equipment (e.g., cookers, water, filters),
    • Have access to sterile injection equipment from a reliable source.
  • If not HIV infected but actively injecting drugs:
    • Are referred for consideration of HIV pre-exposure prophylaxis¹⁰ and if potentially exposed within the past 72 hours (e.g., shared drug preparation or injection equipment with a known or potentially HIV-infected person) HIV post-exposure prophylaxis^11,12
• Remind venues that may encounter unrecognized infections, such as emergency departments and community-based clinical practices (e.g., family medicine, general medicine, prenatal care) of the importance of routine opt-out HIV testing as well as HCV testing per current recommendations^13-15
• Local health departments should notify their state health department and CDC of any suspected clusters of recent HIV or HCV infection.

Recommendations for Healthcare Providers

• Ensure all persons diagnosed with HCV infection are tested for HIV infection,¹⁶ and that all persons diagnosed with HIV infection are tested for HCV infection.¹⁷
• Ensure persons receiving treatment for HIV and/or HCV infection adhere to prescribed therapy and are engaged in ongoing care.
• Encourage HIV and HCV testing of syringe-sharing and sexual partners of persons diagnosed with either infection.
• Report all newly diagnosed HIV and HCV infections to the health department.
• For all persons with substance abuse problems:
  • Refer them for medication-assisted treatment (e.g., opioid substitution therapy) and counseling services,
  • Use effective treatments (e.g., methadone, buprenorphine), as appropriately indicated.
• For any persons for whom opioids are under consideration for pain management:
  • Discuss the risks and benefits of all pain treatment options, including ones that do not involve prescription analgesics.
  • Note that long-term opioid therapy is not associated with reduced chronic pain.¹⁸
• Contact the state or local health department to report suspected clusters of recent HIV or HCV infection.

(Continue . . .)

CDC HAN Advisory On `Drifted’ H3N2 Seasonal Flu Virus

# 9408

 

Late yesterday the CDC issued a HAN Advisory for clinicians on the possibility of seeing `drifted’ H3N2 virus infections during this year’s flu season, along with a reminder on the appropriate and timely use of antivirals. 

 

If this sounds familiar, we looked at this possibility at some length a little over a month ago in A `Drift’ In A Sea Of Influenza Viruses.

 

But briefly, over the summer – and since this year’s flu vaccine components were selected last February – a new, antigenically drifted H3N2 virus has begun to circulate more widely.

 

The rise of this new strain has already prompted  WHO to recommend a strain change for next year’s Southern Hemisphere vaccine formulation from the current A/Texas/50/2012 (H3N2)-like virus to a new A/Switzerland/9715293/2013 (H3N2)-like virus.

 

The most recent FluView report (week 47) shows that of the 85 H3N2 viruses tested since October 1st, 41 (48%) are a good match to the vaccine strain, while 52% were not.  This `mismatch’ is expected to reduce the vaccine’s effectiveness against this drifted strain, although some protection or a reduction in the severity of illness may still result.

 

With this year shaping up to be an H3N2-dominant year, and a possible vaccine `mismatch’ in the works, the CDC is reminding clinicians of value of prescribing neuraminidase inhibitor antiviral medications for severe influenza, or for patients with co-morbidities that raise their risk of seeing serious complications.

 

Despite the constant excoriation of Tamiflu ® and other NI antiviral medications in the press – based primarily on a series of Cochrane reports (see Revisiting Tamiflu Efficacy (Again)) – there are demonstrable benefits to using these medications, particularly when given early and for severe influenza (see The CDC Responds To The Cochrane Tamiflu Study).

Earlier this summer we saw a review in the journal Clinical Infectious Disease that suggested a serious Under Utilization Of Antivirals For At Risk Flu Patients, and a month ago we saw the UK’s PHE reiterate their Influenza Antiviral Recommendations.

 

Although you can never be sure what kind of flu season we will have until it is over, years in which H3N2 viruses have dominated tend to be rougher for the elderly, and the very young,  than years when H1N1 or influenza B dominate. 

 

Despite the expected reduced effectiveness of this year’s flu shot, there are still benefits to getting the vaccine if you haven’t done so already. 

• There are two other strains (H1N1 & Influenza B) covered by the shot,
• Half the H3N2 viruses tested so far are still a `match’  to the vaccine strain
• There may still be some degree of cross-protection afforded against this new strain.

I’ve only posted the summary, so follow the link below to read the full HAN advisory, and the recommendations of antiviral use.

 

CDC Health Advisory Regarding the Potential for Circulation of Drifted Influenza A (H3N2) Viruses

 

CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network
December 3, 2014, 16:00 ET (4:00PM ET)
CDCHAN-00374

CDC is reminding clinicians of the benefits of influenza antiviral medications and urging continued influenza vaccination of unvaccinated patients this influenza season.

Summary

Influenza activity is currently low in the United States as a whole, but is increasing in some parts of the country. This season, influenza A (H3N2) viruses have been reported most frequently and have been detected in almost all states.

During past seasons when influenza A (H3N2) viruses have predominated, higher overall and age-specific hospitalization rates and more mortality have been observed, especially among older people, very young children, and persons with certain chronic medical conditions compared with seasons during which influenza A (H1N1) or influenza B viruses have predominated.

Influenza viral characterization data indicates that 48% of the influenza A (H3N2) viruses collected and analyzed in the United States from October 1 through November 22, 2014 were antigenically "like" the 2014-2015 influenza A (H3N2) vaccine component, but that 52% were antigenically different (drifted) from the H3N2 vaccine virus. In past seasons during which predominant circulating influenza viruses have been antigenically drifted, decreased vaccine effectiveness has been observed. However, vaccination has been found to provide some protection against drifted viruses. Though reduced, this cross-protection might reduce the likelihood of severe outcomes such as hospitalization and death. In addition, vaccination will offer protection against circulating influenza strains that have not undergone significant antigenic drift from the vaccine viruses (such as influenza A (H1N1) and B viruses).

Because of the detection of these drifted influenza A (H3N2) viruses, this CDC Health Advisory is being issued to re-emphasize the importance of the use of neuraminidase inhibitor antiviral medications when indicated for treatment and prevention of influenza, as an adjunct to vaccination.

The two prescription antiviral medications recommended for treatment or prevention of influenza are oseltamivir (Tamiflu®) and zanamivir (Relenza®). Evidence from past influenza seasons and the 2009 H1N1 pandemic has shown that treatment with neuraminidase inhibitors has clinical and public health benefit in reducing severe outcomes of influenza and, when indicated, should be initiated as soon as possible after illness onset. Clinical trials and observational data show that early antiviral treatment can:

• shorten the duration of fever and illness symptoms;
• reduce the risk of complications from influenza (e.g., otitis media in young children and pneumonia requiring antibiotics in adults); and
• reduce the risk of death among hospitalized patients.

(Continue . . .)

 

CDC HAN: Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children

 

# 9117

 

There are a fair number of possible causes for a cluster of acute neurological illness in children, ranging from vector-borne encephalopathies like West Nile Virus, to a variety of polio and non-polio enteroviruses. In recent years, EV-71 has been linked to a number of clusters of AFP (acute flaccid paralysis) around the globe, particularly in Asia, Australia, and the Pacific (see Australia: Acute Flaccid Paralysis & EV71).

 

A month ago, when the EV-D68 virus was first identified in a cluster of sick kids in the Midwest (see Kansas City Outbreak Identified As HEV 68), I mentioned that this rarely reported non-polio enterovirus had been detected in two of five children who developed a rare polio-like syndrome last winter (see Acute Flaccid Paralysis Cases In California) .

 

While this may have simply been an incidental finding, due to the history of other non-polio enteroviruses to cause neurological illness, EV-D68 infection was considered at least plausible cause for these illnesses. The CDC has frequently stated that  `EV-D68 causes primarily respiratory illness, although the full spectrum of disease remains unclear.’

The EV-D68 virus has now spread to more than 40 states, and has likely sickened tens of thousands of children, but until now we’d not heard any credible reports of EV-D68 infected children developing neurological symptoms. Testing for the virus, however, is both difficult and time consuming – and the battery of tests required to rule out other causes of neurological illness can take considerable time – and so there are often lags in reporting.

 

Given the recent surge in enterovirus infections across the nation, and their history of occasionally producing neurological illness, it is not altogether surprising that health authorities in Denver, Colorado have now reported a cluster of children presenting with acute neurological symptoms following recent respiratory infections.

 

To date, four of nine have tested positive for the EV-D68 virus. 

With the caveat that the etiology remains unknown, the CDC is anxious to identify other recent cases or clusters, and to nail down the cause (or causes) of these illnesses. 

 

Last night the CDC issued the following HAN (Health Alert Network)  Advisory to clinicians, with instructions on reporting and recommendations for testing. 

 

Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children

Summary

The Centers for Disease Control and Prevention (CDC) is working closely with the Colorado Department of Public Health and Environment (CDPHE) and Children’s Hospital Colorado to investigate a cluster of nine pediatric patients hospitalized with acute neurologic illness of undetermined etiology. The illness is characterized by focal limb weakness and abnormalities of the spinal cord gray matter on MRI. These illnesses have occurred since August 1, 2014 coincident with an increase of respiratory illnesses among children in Colorado. The purpose of this HAN Advisory is to provide awareness of this neurologic syndrome under investigation with the aim of determining if children with similar clinical and radiographic findings are being cared for in other geographic areas. Guidance about reporting cases to state and local health departments and CDC is provided. Please disseminate this information to infectious disease specialists, intensive care physicians, pediatricians, neurologists, radiologists/neuroradiologists, infection preventionists, and primary care providers, as well as to emergency departments and microbiology laboratories.

Background

The CDPHE, Children’s Hospital Colorado, and CDC are investigating nine cases of acute neurologic illness among pediatric patients. The cases were identified during August 9–September 17, 2014 among children aged 1–18 years (median age 10 years). Most of the children were from the Denver metropolitan area. All were hospitalized. Common features included acute focal limb weakness and specific findings on magnetic resonance imaging (MRI) of the spinal cord consisting of non-enhancing lesions largely restricted to the gray matter. In most cases, these lesions spanned more than one level of the spinal cord. Some also had acute cranial nerve dysfunction with correlating non-enhancing brainstem lesions on MRI. None of the children experienced altered mental status or seizures. None had any cortical, subcortical, basal ganglia, or thalamic lesions on MRI. Most children reported a febrile respiratory illness in the two weeks preceding development of neurologic symptoms. In most cases, cerebrospinal fluid (CSF) analyses demonstrated mild-moderate pleocytosis (increased cell count in the CSF) consistent with an inflammatory or infectious process. CSF testing to date has been negative for West Nile virus and enteroviruses, including poliovirus. Nasopharyngeal specimens were positive for rhinovirus/enterovirus in six out of eight patients that were tested. Of the six positive specimens, four were typed as EV-D68, and the other two are pending typing results. Testing of other specimens is still in process. Eight out of nine children have been confirmed to be up to date on polio vaccinations. Epidemiologic and laboratory investigations of these cases are ongoing.

The United States is currently experiencing a nationwide outbreak of EV-D68 associated with severe respiratory disease. The possible linkage of this cluster of neurologic disease to this large EV-D68 outbreak is part of the current investigation. CDC is seeking information about other similar neurologic illnesses in all states, especially cases clustered in time and place. CDC has particular interest in characterizing the epidemiology and etiology of such cases.

Recommendations

• Patients who meet the following case definition should be reported to state and local health departments:

  Patients ≤21 years of age with

  1. Acute onset of focal limb weakness occurring on or after August 1, 2014;

  AND

  1. An MRI showing a spinal cord lesion largely restricted to gray matter.

• State and local health departments should report patients meeting the case definition to CDC using a brief patient summary form (www.cdc.gov/non-polio-enterovirus/investigation/). State health departments should send completed summary forms to CDC by email at limbweakness@cdc.gov.
• Providers treating patients meeting the above case definition should consult with their local and state health department for laboratory testing of stool, respiratory, and cerebrospinal fluid specimens for enteroviruses, West Nile virus, and other known infectious etiologies.
• Health departments may contact CDC for further laboratory and epidemiologic support by phone through the CDC Emergency Operations Center (770-488-7100), or by email at limbweakness@cdc.gov. Confirmation of the presence of EV-D68 currently requires typing by molecular sequencing.

CDC HAN Advisory On EV-D68

 

 

# 9071

 

The respiratory illness outbreak which was first reported last month in Kansas City & Chicago (see Kansas City Outbreak Identified As HEV 68), and that we’ve been following for more than two weeks (see Enterovirus D-68 (HEV-D68) Update) continues to spread across the nation with confirmed or suspected cases reported now in well over a dozen states, including New York, Iowa, Georgia,and yesterday in  Indiana.

 

The culprit, a rarely detected non-polio enterovirus dubbed EV-D68, causes mostly respiratory symptoms and has sent thousands of kids to doctors and Emergency rooms around the nation since school let back into session last month. 

For most kids, this is nothing more than a nasty summer `cold’, but for some, it can lead to serious respiratory illness, and hospitalization may be required. This week the CDC held a press briefing and released a FAQ file (see CDC EV-D68 Update & FAQ)  and next Tuesday the CDC will hold a COCA Call on the virus for clinicians. 

 

Last night the CDC issued the following HAN (Health Alert Network) Advisory.   An advisory is a 2nd tier notice that: Provides important information for a specific incident or situation; may not require immediate action.

 

Severe Respiratory Illness Associated with Enterovirus D68 – Multiple States, 2014

Summary

The Centers for Disease Control and Prevention (CDC) is working closely with hospitals and local and state health departments to investigate recent increases in hospitalizations of patients with severe respiratory illness. Enterovirus D68 (EV-D68) has been detected in specimens from children with severe illness in Missouri and Illinois. Investigations into suspected clusters in other jurisdictions are ongoing. The purpose of this HAN Advisory is to provide awareness of EV-D68 as a possible cause of acute unexplained respiratory illness, and to provide guidance to state health departments and health care providers. Please disseminate this information to infectious disease specialists, intensive care physicians, pediatricians, internists, infection preventionists, and primary care providers, as well as to emergency departments and microbiology laboratories.

Background

Enteroviruses are associated with various clinical symptoms, from mild to severe. EV-D68 causes primarily respiratory illness, although the full spectrum of disease remains unclear. EV-D68 was originally isolated in 1962 and, since then, has been reported rarely in the United States. Small clusters of EV-D68 associated with respiratory illness were reported in the United States during 2009–2010.There are no available vaccines or specific treatments for EV-D68, and clinical care is supportive.

In August 2014, a children’s hospital in Kansas City, Missouri, and one in Chicago, Illinois, notified CDC of increases in pediatric patients examined and hospitalized with severe respiratory illness, including some admitted to pediatric intensive care units. Both hospitals also reported recent increases in detection of rhinovirus/enterovirus, in initial screening with a respiratory virus panel. Nasopharyngeal specimens from patients with recent onset of severe symptoms from both facilities were sequenced by the CDC Picornavirus Laboratory. EV-D68 was identified in 19 of 22 specimens from Kansas City and in 11 of 14 specimens from Chicago. Admissions for severe respiratory illness have continued at both facilities at rates higher than expected for this time of year. CDC has been notified by various states of similar clusters of respiratory illness, though confirmation of EV-D68 in these potential clusters is still under way.

Of these severely ill patients who were confirmed positive for EV-D68 from both hospitals, all presented with difficulty breathing and hypoxemia, and some with wheezing. Notably, most patients were afebrile at presentation and throughout the hospital course. Approximately two thirds of cases had a previous medical history of asthma or wheezing, but both hospitals reported some patients with no known underlying respiratory illness. Ages ranged from 6 weeks through 16 years, with median ages of 4 and 5 years in Kansas City and Chicago, respectively. Most patients were admitted to the pediatric intensive care unit. Of the 30 patients who were positive for EV-D68, two required mechanical ventilation (one of whom also received extracorporeal membrane oxygenation) and six required bilevel positive airway pressure ventilation. It should be noted that specimens from only the most severe cases have been typed at this time, and so these findings may not reflect the full spectrum of disease.

Additional details about these EV-D68 clusters can be found in the September 8, 2014, MMWR Early Release: (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0908a1.htm?s_cid=mm63e0908a1_e)

Recommendations

Clinical Care:

• Health care providers should consider EV-D68 as a possible cause of acute, unexplained severe respiratory illness, even in the absence of fever.
• Although the findings to date have been in children, EV-D68 may also affect adults.

Laboratory Testing:

• Providers should consider laboratory testing of respiratory specimens for enteroviruses when the cause of respiratory infection in severely ill patients is unclear.
• Confirmation of the presence of EV-D68 requires typing by molecular sequencing.
• Providers may contact state or local health departments for further enterovirus typing. CDC is available for consultation.
• Health departments may contact CDC for further enterovirus typing.
• CDC is currently prioritizing respiratory specimens from patients with severe respiratory illness who are known to be positive for rhinovirus/enterovirus from initial screening assays.
• Please visit the CDC EV-D68 website (http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html) for information on specimen submission. Completion of a brief patient summary form is required with each specimen submission to CDC.

Infection Control:

• Routes of transmission for EV-D68 are not fully understood.
• Infection control guidelines for hospitalized patients with EV-D68 infection should include standard precautions, and contact precautions in certain situations, as is recommended for all enteroviruses (http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
• As EV-D68 is a cause of clusters of respiratory illness, similar to rhinoviruses, droplet precautions also should be considered as an interim recommendation until there is more definitive information available on appropriate infection control.
• As EV-D68 is a non-enveloped virus, environmental disinfection of surfaces in healthcare settings should be performed using a hospital-grade disinfectant with an EPA label claim for any of several non-enveloped viruses (e.g. norovirus, poliovirus, rhinovirus). Disinfectant products should be used in accordance with the manufacturer’s instructions for the specific label claim and in a manner consistent with environmental infection control recommendations (http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf).

Reporting:

• Providers should report suspected clusters of severe respiratory illness to local and state health departments.
• EV-D68 is not nationally notifiable, but state and local health departments may have additional guidance on reporting.
• Health departments may contact CDC for epidemiologic support. Please contact Dr. Claire Midgley (cmidgley@cdc.gov) with brief descriptions of possible clusters.

For more information:
For additional information, please consult the CDC enterovirus D68 website: (http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html)

CDC HAN: Evaluation Of US Patients Suspect Of Having Ebola Virus

 

# 8905

 

While the risks of seeing any significant spread of Ebola in the United States are considered negligible, given the extent and likely duration of outbreak in Western Africa and the number of international travelers and response personnel in the the region, it isn’t inconceivable that we could see some imported cases.  

 

Add in the imminent medical evacuation of at least two Americans with the virus, and you can understand why the CDC has been generating an incredible amount of guidance this week on Ebola.

 

On Monday we saw the CDC Teleconference & HAN Notice On Ebola.  Three days later (Thursday) we saw another teleconference to announce a CDC Statement On Travel Warnings & Ebola Situation In West Africa, followed on Friday by the release of fresh CDC Infection Control Guidance on Ebola.

 

Last night, the CDC published another HAN (Health Alert Network) Advisory on the handling of suspected Ebola cases in the United States.

 

 

This is an official

CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network
August 1, 2014 20:00 ET (8:00 PM ET)
CDCHAN-00364

Summary

The Centers for Disease Control and Prevention (CDC) continues to work closely with the World Health Organization (WHO) and other partners to better understand and manage the public health risks posed by Ebola Virus Disease (EVD). To date, no cases have been reported in the United States. The purpose of this health update is 1) to provide updated guidance to healthcare providers and state and local health departments regarding who should be suspected of having EVD, 2) to clarify which specimens should be obtained and how to submit for diagnostic testing, and 3) to provide hospital infection control guidelines.

U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures. Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, hospital epidemiologists, infection control professionals, and hospital administration, as well as to emergency departments and microbiology laboratories.

Background

CDC is working with the World Health Organization (WHO), the ministries of health of Guinea, Liberia, and Sierra Leone, and other international organizations in response to an outbreak of EVD in West Africa, which was first reported in late March 2014. As of July 27, 2014, according to WHO, a total of 1,323 cases and 729 deaths (case fatality 55-60%) had been reported across the three affected countries. This is the largest outbreak of EVD ever documented and the first recorded in West Africa.

EVD is characterized by sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms, such as myalgia, headache, vomiting, and diarrhea. Patients with severe forms of the disease may develop hemorrhagic symptoms and multi-organ dysfunction, including hepatic damage, renal failure, and central nervous system involvement, leading to shock and death. The fatality rate can vary from 40-90%.

In outbreak settings, Ebola virus is typically first spread to humans after contact with infected wildlife and is then spread person-to-person through direct contact with bodily fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk. The incubation period is usually 8–10 days (ranges from 2–21 days). Patients can transmit the virus while febrile and through later stages of disease, as well as postmortem, when persons touch the body during funeral preparations.

Patient Evaluation Recommendations to Healthcare Providers

Healthcare providers should be alert for and evaluate suspected patients for Ebola virus infection who have both consistent symptoms and risk factors as follows: 1) Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND 2) Epidemiologic risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas. Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.

Testing of patients with suspected EVD should be guided by the risk level of exposure, as described below:

CDC recommends testing for all persons with onset of fever within 21 days of having a high-risk exposure. A high-risk exposure includes any of the following:

• percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),
• laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
• participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.

For persons with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/µL and/or elevated transaminases) or unknown.

Persons considered to have a low-risk exposure include persons who spent time in a healthcare facility where EVD patients are being treated (encompassing healthcare workers who used appropriate PPE, employees not involved in direct patient care, or other hospital patients who did not have EVD and their family caretakers), or household members of an EVD patient without high-risk exposures as defined above. Persons who had direct unprotected contact with bats or primates from EVD-affected countries would also be considered to have a low-risk exposure. Testing is recommended for persons with a low-risk exposure who develop fever with other symptoms and have unknown or abnormal blood work findings. Persons with a low-risk exposure and with fever and abnormal blood work findings in absence of other symptoms are also recommended for testing. Asymptomatic persons with high- or low-risk exposures should be monitored daily for fever and symptoms for 21 days from the last known exposure and evaluated medically at the first indication of illness.

Persons with no known exposures listed above but who have fever with other symptoms and abnormal bloodwork within 21 days of visiting EVD-affected countries should be considered for testing if no other diagnosis is found. Testing may be indicated in the same patients if fever is present with other symptoms and blood work is abnormal or unknown. Consultation with local and state health departments is recommended.

If testing is indicated, the local or state health department should be immediately notified. Healthcare providers should collect serum, plasma, or whole blood. A minimum sample volume of 4 mL should be shipped refrigerated or frozen on ice pack or dry ice (no glass tubes), in accordance with IATA guidelines as a Category B diagnostic specimen. Please refer to http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html for detailed instructions and a link to the specimen submission form for CDC laboratory testing.

Recommended Infection Control Measures

U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures, including standard, contact, and droplet precautions. Early recognition and identification of patients with potential EVD is critical. Any U.S. hospital with suspected patients should follow CDC’s Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals (http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html). These recommendations include the following:

• Patient placement: Patients should be placed in a single patient room (containing a private bathroom) with the door closed.
• Healthcare provider protection: Healthcare providers should wear: gloves, gown (fluid resistant or impermeable), shoe covers, eye protection (goggles or face shield), and a facemask. Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.
• Aerosol-generating procedures: Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 filtering facepiece respirator or higher) and the procedure should be performed in an airborne isolation room.
• Environmental infection control: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, emesis, feces and other body secretions represent potentially infectious materials. Appropriate disinfectants for Ebola virus and other filoviruses include 10% sodium hypochlorite (bleach) solution, or hospital-grade quaternary ammonium or phenolic products. Healthcare providers performing environmental cleaning and disinfection should wear recommended PPE (described above) and consider use of additional barriers (e.g., shoe and leg coverings) if needed. Face protection (face shield or facemask with goggles) should be worn when performing tasks such as liquid waste disposal that can generate splashes. Follow standard procedures, per hospital policy and manufacturers’ instructions, for cleaning and/or disinfection of environmental surfaces, equipment, textiles, laundry, food utensils and dishware.

Recommendations to Public Health Officials

If public health officials have a patient that is suspected of having EVD or has potentially been exposed and intends to travel, please contact CDC’s Emergency Operations Center 1 (770) 488-7100.

CDC Teleconference & HAN Notice On Ebola

 

# 8877

 

While stressing that Ebola currently poses little risk to the general U.S. population, the CDC held a teleconference yesterday afternoon (see Transcript  & Audio recording) to provide an update on the outbreak in West Africa and to announce the release of a CDC HAN Advisory providing information for clinicians who might encounter travel associated cases.

 

HAN messages (Alert, Advisory, Update, or Info) are designed to ensure that communities, agencies, health care professionals, and the general public are able to receive timely information on important public health issues.

 

An `Advisory’ is a second tier message that provides important information for a specific incident or situation, but may not require immediate action.  First the  advisory, after which I’ll have a bit more.

 

Ebola Virus Disease Confirmed in a Traveler to Nigeria, Two U.S. Healthcare Workers in Liberia

Distributed via the CDC Health Alert Network
July 28, 2014, 16:30 ET (4:30 PM ET)
CDCHAN-00363

Summary

Nigerian health authorities have confirmed a diagnosis of Ebola Virus Disease (EVD) in a patient who died on Friday in a hospital in Lagos, Nigeria, after traveling from Liberia on July 20, 2014. The report marks the first Ebola case in Nigeria linked to the current outbreak in the West African countries of Guinea, Sierra Leone, and Liberia. Health authorities also reported this weekend that two U.S. citizens working in a hospital in Monrovia, Liberia, have confirmed Ebola virus infection. These recent cases, together with the continued increase in the number of Ebola cases in West Africa, underscore the potential for travel-associated spread of the disease and the risks of EVD to healthcare workers. While the possibility of infected persons entering the U.S. remains low, the Centers for Disease Control and Prevention (CDC) advises that healthcare providers in the U.S. should consider EVD in the differential diagnosis of febrile illness, with compatible symptoms, in any person with recent (within 21 days) travel history in the affected countries and consider isolation of those patients meeting these criteria, pending diagnostic testing.

Background

CDC is working with the World Health Organization (WHO), the ministries of health of Guinea, Liberia, and Sierra Leone, and other international organizations in response to an outbreak of EVD in West Africa, which was first reported in late March 2014. As of July 23, 2014, according to WHO, a total of 1,201 cases and 672 deaths (case fatality 55-60%) had been reported in Guinea, Liberia, and Sierra Leone. This is the largest outbreak of EVD ever documented and the first recorded in West Africa.

EVD is characterized by sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms, such as myalgia, headache, vomiting, and diarrhea. Patients with severe forms of the disease may develop multi-organ dysfunction, including hepatic damage, renal failure, and central nervous system involvement, leading to shock and death.

In outbreak settings, Ebola virus is typically first spread to humans after contact with infected wildlife and is then spread person-to-person through direct contact with bodily fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk. The incubation period is usually 8–10 days (rarely ranging from 2–21 days). Patients can transmit the virus while febrile and through later stages of disease, as well as postmortem, when persons contact the body during funeral preparations.

On July 25, the Nigerian Ministry of Health confirmed a diagnosis of EVD in a man who died in a hospital in the country’s capital of Lagos (population ~21 million). The man had been in isolation in the hospital since arriving at the Lagos airport from Liberia, where he apparently contracted the infection. Health authorities are investigating whether passengers or crew on the plane or other persons who had contact with the ill traveler are at risk for infection.

In addition, health authorities have reported that two U.S. healthcare workers at ELWA hospital in Monrovia, Liberia, have confirmed Ebola virus infection. One of the healthcare workers, a physician who worked with Ebola patients in the hospital, is symptomatic and in isolation. The other healthcare worker, a hygienist, developed fever but is showing no other signs of illness. The physician is an employee of Samaritan’s Purse, a North Carolina-based aid organization that has provided extensive assistance in Liberia since the beginning of the current outbreak. The other healthcare worker works with Soudan Interior Mission (SIM) in Liberia and was helping the joint SIM/Samaritan’s Purse team.

The recent cases in a traveler and in healthcare workers demonstrate the risk for spread of EVD in these populations. While no EVD cases have been reported in the United States, a human case, caused by a related virus, Marburg virus, occurred in Denver, Colorado in 2008. Successful implementation of standard precautions was sufficient to limit onward transmission. Other imported cases of viral hemorrhagic fever disease were also successfully managed through effective barrier methods, including a recent Lassa fever case in Minnesota.

Recommendations

EVD poses little risk to the U.S. general population at this time. However, U.S. healthcare workers are advised to be alert for signs and symptoms of EVD in patients with compatible illness who have a recent (within 21 days) travel history to countries where the outbreak is occurring, and should consider isolation of those patients meeting these criteria, pending diagnostic testing.

For More Information

Additional information on EVD can be found at: http://www.cdc.gov/ebola

Interim Guidance on EVD for healthcare workers can be found at: http://www.cdc.gov/vhf/abroad/healthcare-workers.html

Travel notices for each country can be found at:
Guinea: http://wwwnc.cdc.gov/travel/notices/alert/ebola-guinea
Liberia: http://wwwnc.cdc.gov/travel/notices/alert/ebola-liberia
Sierra Leone: http://wwwnc.cdc.gov/travel/notices/alert/ebola-sierra-leone

 

Although the odds of having an Ebola infected individual fly out of Western Africa and arrive in the United States is considered low, it is certainly not inconceivable  - particularly given the incubation period (2 –21 days) and the number of American medical and humanitarian aid workers that are currently in the hot zone.

 

Last February, in The Global Reach Of Infectious Disease, we looked at rationale behind several national and international initiatives designed to deal with the growing threat of the international spread of infectious diseases. 

 

• In WHO: IHR & Global Health Security, we looked at the large number of member states which have yet to meet the core surveillance and response requirements of the International Health Regulations that went into force in 2007.
• A recent Assessment by the Director of National Security (see DNI: An Influenza Pandemic As A National Security Threat) found the global spread of infectious diseases – along with cyber attacks, terrorism, extreme weather events, WMDs, food and water insecurity, and global economic concerns.- constitutes a genuine threat to national security.
• While in CIDRAP On The Global Health Security Agenda, we looked at a 26 nation initiative to improve global health surveillance & emergency response in this age of rising infectious diseases. 

 

You’ll find more on the CDC’s Global Health Website at:

 

Why Global Health Security Matters

Disease Threats Can Spread Faster and More Unpredictably Than Ever Before

(Excerpt)

A disease threat anywhere can mean a threat everywhere. It is defined by

• the emergence and spread of new microbes;
• globalization of travel and trade;
• rise of drug resistance; and
• potential use of laboratories to make and release—intentionally or not—dangerous microbes.

(Continue . . .)

 

 

A sobering reminder that in this second decade of the 21st century, there is really no inhabited place on earth that is truly remote anymore, and virtually no serious emerging infectious disease outbreak that we can afford to ignore.

CDC HAN: Responding to Imported MERS-CoV Cases

 

 

# 8565

 

For well over a year the CDC has been preparing for the day when a MERS-CoV infected individual arrived in the United States.  As most of my readers already know, that day finally happened last week (see CDC: First Imported MERS Coronavirus Case In the United States), prompting a full public health response by state, local, and national health authorities.

 

As long as the virus continued to circulate in the Middle East, its arrival in the United States was pretty much a foregone conclusion – the only question being: when?   And as the number of cases in Saudi Arabia and the UAE increase, the odds favor additional introductions of the virus in the future.

 

Late yesterday the CDC released a HAN (Health Alert Network) advisory for clinicians, healthcare facilities, and those working in public health on dealing with a confirmed or suspected MERS cases, that builds upon a growing library of guidance documents released over the past 12 months.

 

As we saw with the H1N1 pandemic of 2009, guidance on emerging infectious disease threats tends to evolve over time, as more is learned about the threat.  Some of the CDC guidance documents we’ve looked at over the past year include:

 

CDC: Infection Control Guidance For Home Care Of MERS-CoV Cases

MMWR: Updated MERS-CoV Guidance For The Public, Clinicians & Public Health Workers

CDC HAN: Updated Guidelines For Evaluation Of MERS-CoV

MMWR: MERS-CoV Update – June 7th

 

 

Below you’ll find excerpts from the latest HAN Alert.  I’ve skipped the `background’ section in order to focus on their recommendations. Follow the link to read it in its entirety.  I’ll have a bit more when you return.

 

Confirmed Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Case in Indiana, 2014

Recommendations

Healthcare providers should be alert for and evaluate patients for MERS-CoV infection who 1) develop severe acute lower respiratory illness within 14 days after traveling from countries in or near the Arabian Peninsula, excluding those who only transited at airports in the region; or 2) are close contacts of a symptomatic recent traveler from this area who has fever and acute respiratory illness; or 3) are close contacts of a confirmed case. For these patients, testing for MERS-CoV and other respiratory pathogens can be done simultaneously. Positive results for another respiratory pathogen (e.g H1N1 Influenza) should not necessarily preclude testing for MERS-CoV because co-infection can occur.

Clusters of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) without recognized links to cases of MERS-CoV or to travelers from countries in or near the Arabian peninsula should be evaluated for common respiratory pathogens. If the illnesses remain unexplained, providers should consider testing for MERS-CoV, in consultation with state and local health departments. Healthcare professionals should immediately report to their state or local health department any person being evaluated for MERS-CoV infection as a patient under investigation (PUI). Additional information, including criteria for PUI are at http://www.cdc.gov/coronavirus/mers/interim-guidance.html. Healthcare providers should contact their state or local health department if they have any questions.

Persons at highest risk of developing infection are those with close contact to a case, defined as any person who provided care for a patient, including a healthcare provider or family member not adhering to recommended infection control precautions (i.e., not wearing recommended personal protective equipment), or had similarly close physical contact; or any person who stayed at the same place (e.g. lived with, visited) as the patient while the patient was ill.

Healthcare professionals should carefully monitor for the appearance of fever (T> 100F) or respiratory symptoms in any person who has had close contact with a confirmed case, probable case, or a PUI while the person was ill. If fever or respiratory symptoms develop within the first 14 days following the contact, the individual should be evaluated for MERS-CoV infection. Ill people who are being evaluated for MERS-CoV infection and do not require hospitalization for medical reasons may be cared for and isolated in their home. (Isolation is defined as the separation or restriction of activities of an ill person with a contagious disease from those who are well.).

Providers should contact their state or local health department to determine whether home isolation, home quarantine or additional guidance is indicated since recommendations may be modified as more data becomes available. Additional information on home care and isolation guidance is available at http://www.cdc.gov/coronavirus/mers/hcp/home-care.html. Healthcare providers should adhere to recommended infection-control measures, including standard, contact, and airborne precautions, while managing symptomatic contacts and patients who are persons under investigation or who have probable or confirmed MERS-CoV infections. For CDC guidance on MERS-CoV infection control in healthcare settings, see Interim Infection Prevention and Control Recommendations for Hospitalized Patients with MERS-CoV at http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html.

For suspected MERS-CoV cases, healthcare providers should collect the following specimens for submission to CDC or the appropriate state public health laboratory: nasopharyngeal swab, oropharyngeal swab (which can be placed in the same tube of viral transport medium), sputum, serum, and stool/rectal swab. Recommended infection control precautions should be utilized when collecting specimens. Specimens can be sent using category B shipping containers. Providers should notify their state or local health departments if they suspect MERS-CoV infection in a person. State or local health departments should notify CDC if MERS-CoV infection in a person is suspected. Additional information is available at http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html.

Additional or modified recommendations may be forthcoming as the investigation proceeds.

For More Information

For more information, for consultation, or to report possible cases, please contact the CDC Emergency Operations Center at (770) 488-7100.

(Continue . . . )

 

 

During  the SARS epidemic of 2003, the isolation of those who were symptomatic, and the (usually) home quarantining of those who were exposed (but not showing signs of illness) proved to be a powerful public health tool in places like Canada, Hong Kong, and Singapore. 

 

The CDC defines these terms as:

• Isolation applies to persons who are known to be ill with a contagious disease.
• Quarantine applies to those who have been exposed to a contagious disease but who may or may not become ill.

 

During the SARS epidemic, Isolation was used in the United States for patients who were ill, but since transmission of the virus was very limited here, quarantine was not recommended for those exposed (cite).

 

For a look at the use of quarantines for the control of infectious disease, including with SARS, you may wish to revisit  EID Journal: A Brief History Of Quarantine. For now, the CDC is simply advising:

 

Providers should contact their state or local health department to determine whether home isolation, home quarantine or additional guidance is indicated since recommendations may be modified as more data becomes available.

 

I would suspect that until more is learned about the ability (or inability) of the MERS virus to transmit from pre-symptomatic or asymptomatic cases, public health officials are likely to approach these early imported cases with an abundance of caution.

 

Local news reports indicate that exposed HCWs in Indiana have been asked to remain home, and to monitor their health, during the 14 day incubation period (see RTV 6 coverage).  Since they are not ill, technically they are in home quarantine, not isolation, as indicated by the report.

 

As we’ve seen in the past with Dengue, West Nile Virus and last January with the H5N1 virus  (see CDC Statement On 1st H5N1 Case In North America) - and more recently in Minnesota: Rare Imported Case Of Lassa Fever – rare or exotic diseases are skilled international travelers.

 

Vast oceans, long travel times, and political borders are no longer obstacles to their spread.

 

A reminder that an outbreak of a disease anywhere in the world can – given enough time – end up in our own backyard. Making it in our best interests to promote better global surveillance and response, no matter how far removed from us they may seem at the time.

CDC HAN Advisory On Canadian H5N1 Case

 

 

# 8175

 

While last week’s announced H5N1 fatality in Canada – the first reported human H5N1 infection in the Americas – was almost certainly an  isolated case with no sign of further spread, the potential for seeing more novel flu cases (H5N1 & H7N9) imported into North America remains, and so yesterday the CDC issued a HAN Advisory to clinicians on what to look for.

 

Although  the Canadian patient has recent travel history to China, she did not exhibit typical flu symptoms, and so testing for H5N1 was delayed.  As I wrote last week in Atypical Influenza (H5N1,H7N9, pH1N1) Presentations, these novel flu viruses can sometimes present with confusing, non-respiratory symptoms.

 

HAN Health Advisories are a second tier alert, and provides important information for a specific incident or situation, but may not require immediate action. I’ve only posted excerpts from this notice, follow the link below to read it in its entirety.

 

Human Infection with Avian Influenza A (H5N1) Virus

Summary and Background

On January 8, 2014, the Public Health Agency of Canada reported the first confirmed case of human infection with avian influenza A (H5N1) virus identified in North America. The patient exhibited symptoms while returning from travel to Beijing, China, on December 27, 2013. For more information on this patient’s travel itinerary, please refer to a Public Health Agency of Canada technical briefing at http://www.phac-aspc.gc.ca/media/nr-rp/2014/2014_0108a-eng.php. The patient was hospitalized on January 1, 2014, and subsequently died on January 3, 2014. Investigations by Canadian public health officials are ongoing. Since avian influenza A (H5N1) viruses have only been rarely, and never sustainably, transmitted from person to person, there is a very low risk of subsequent related cases. To date, no cases of human infection with avian influenza A (H5N1) viruses have been reported in the United States.

This case is a reminder that novel influenza A viruses, including avian influenza A (H5N1) virus, can infect and cause severe respiratory illness in humans. The clinical presentation of human infection with avian influenza A viruses varies considerably. Most reports of H5N1 in humans, however, have described severe illness, including fulminant pneumonia leading to respiratory failure, acute respiratory distress syndrome, and death. Other reported H5N1 complications include encephalitis, septic shock, and multi-organ failure.

 

Clinicians should consider the possibility of avian influenza A (H5N1) virus infection in persons exhibiting symptoms of severe respiratory illness who have appropriate travel or exposure history. This includes persons with recent travel (within 10 days of illness onset) to areas where human cases of avian influenza A (H5N1) virus infection have been detected or where avian influenza A (H5N1) viruses are known to be circulating in animals¹. Rapid detection and characterization of novel influenza A viruses remain critical components of national efforts to prevent further cases, evaluate clinical illness associated with them, and assess any ability for these viruses to spread among humans.

 

State health departments are encouraged to investigate potential human cases of avian influenza A (H5N1) virus infection as described below and should notify CDC within 24 hours of identifying a probable or confirmed case of novel influenza A virus infection, including avian influenza A (H5N1) virus infection (http://www.cdc.gov/flu/avianflu/h5n1/case-definitions.htm).

Clinicians and state health departments should also be aware that human infection with avian influenza A (H7N9) viruses have been reported among persons in China and Taiwan since April 2013, and may exhibit similar symptoms to those of influenza A (H5N1), including pneumonia, respiratory failure, and acute respiratory distress syndrome. Influenza A (H7N9) infections in humans have also been associated with high mortality. No cases of influenza A (H7N9) infections in humans have been reported in North America. Potential cases of human infection with influenza A (H7N9) virus should also be investigated, using current case definitions and testing recommendations for avian influenza A (H7N9) virus (http://www.cdc.gov/flu/avianflu/healthprofessionals.htm).

Interim Recommendations for Clinicians and State and Local Health Departments

Case Investigation and Testing Recommendations
Patients who meet both the clinical and exposure criteria described below should be tested for avian influenza A (H5N1) virus infection by reverse-transcription polymerase chain reaction (RT-PCR) assay using H5-specific primers and probes. Decisions on diagnostic testing for influenza using RT-PCR should be made using available clinical and epidemiologic information, and additional persons in whom clinicians suspect avian influenza A (H5N1) virus infection also should be tested. For more information on laboratory testing of persons under investigation for avian influenza A (H5N1) virus infection, please see http://www.cdc.gov/flu/avianflu/healthprofessionals.htm. Guidance on testing, treatment, and infection control will be updated by CDC as more information becomes available.

Clinical Illness Criteria

1. Patients with new-onset severe acute respiratory illness requiring hospitalization (i.e., illness of suspected infectious etiology that is severe enough to require inpatient medical care in the judgment of the treating clinician).

Exposure Criteria

1. Patients with recent travel (within 10 days of illness onset) to areas where human cases of avian influenza A (H5N1) virus infection have been detected or where avian influenza A (H5N1) viruses are known to be circulating in animals¹.
   OR
2. Patients who have had recent close contact (within 10 days of illness onset) with suspected² or confirmed cases of human infection with avian influenza A (H5N1) virus. Close contact may be regarded as coming within about 6 feet (2 meters) or within the room or care area of a person with a suspected or confirmed case while the person was ill (beginning 1 day prior to illness onset and continuing until resolution of illness). Close contacts include healthcare personnel providing care for a person with a suspected or confirmed case, family members of a person with a suspected or confirmed case, persons who lived with or stayed overnight with a person with a suspected or confirmed case, and others who have had similar close physical contact, especially without the use of respiratory protection.
   OR
3. Persons with an unprotected exposure to avian influenza A (H5N1) virus in a laboratory setting.

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CDC HAN Advisory On Early pH1N1 Influenza Activity

 

 

# 8104

 

After a couple of lackluster influenza seasons immediately following the 2009 pandemic, last year saw a particularly nasty H3N2 season, with some of the highest hospitalization and P&I mortality rates (particularly among the elderly) that we’d seen in a decade. 

 

This year, it is the 2009 H1N1 virus (aka pH1N1) that is dominant, and it has already made a serious impact, particularly in the Southern tier of states (see Texas DSHS Statement On Recent Spike In Flu Activity). Unlike H3N2, which generally impacts the elderly hardest, H1N1 has a history of skewing towards younger patients.

 

Late yesterday the CDC released a HAN ADVISORY to clinicians advising them of this early spike in flu activity, and the dominance of the pH1N1 strain. They continue to recommend vaccination, and the early administration of antivirals for anyone with confirmed or suspected influenza who is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for influenza complications.

You’ll find excerpts from this HAN advisory below.  Follow the link to read it in its entirety.

 

Distributed via the CDC Health Alert Network
December 24, 2013, 14:30 ET (2:30 PM ET)
CDCHAN-00359

Notice to Clinicians: Early Reports of pH1N1-Associated Illnesses for the 2013-14 Influenza Season

Summary

From November through December 2013, CDC has received a number of reports of severe respiratory illness among young and middle-aged adults, many of whom were infected with influenza A (H1N1) pdm09 (pH1N1) virus. Multiple pH1N1-associated hospitalizations, including many requiring intensive care unit (ICU) admission, and some fatalities have been reported. The pH1N1 virus that emerged in 2009 caused more illness in children and young adults, compared to older adults, although severe illness was seen in all age groups. While it is not possible to predict which influenza viruses will predominate during the entire 2013-14 influenza season, pH1N1 has been the predominant circulating virus so far. For the 2013-14 season, if pH1N1 virus continues to circulate widely, illness that disproportionately affects young and middle-aged adults may occur.

 

Seasonal influenza contributes to substantial morbidity and mortality each year in the United States. In the 2012-13 influenza season, CDC estimates that there were approximately 380,000 influenza-associated hospitalizations [1]. Although influenza activity nationally is currently at low levels, some areas of the United States are already experiencing high activity, and influenza activity is expected to increase during the next few weeks.

 

The spectrum of illness observed thus far in the 2013-14 season has ranged from mild to severe and is consistent with that of other influenza seasons. While CDC has not detected any significant changes in pH1N1 viruses that would suggest increased virulence or transmissibility, the agency is continuing to monitor for antigenic and genetic changes in circulating viruses, as well as watching morbidity and mortality surveillance systems that might indicate increased severity from pH1N1 virus infection. In addition, CDC is actively collaborating with state and local health departments in investigation and control efforts.

 

CDC recommends annual influenza vaccination for everyone 6 months and older. Anyone who has not yet been vaccinated this season should get an influenza vaccine now. While annual vaccination is the best tool for prevention of influenza and its complications, treatment with antiviral drugs (oral oseltamivir and inhaled zanamivir) is an important second line of defense for those who become ill to reduce morbidity and mortality. Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for influenza complications.

(Continue . . . )

 

A personal note: I know several people who have already been hit very hard by this year’s `flu’, and they have described it as being particularly `nasty’.  If you haven’t taken this year’s flu shot, it isn’t too late to do so.  It isn’t perfect protection, but can probably cut your odds of contracting the flu in half.

And it is particularly important to maintain good flu hygiene right now.   The CDC recommends:

• Wash your hands often with soap and water or an alcohol-based hand rub.
• Avoid touching your eyes, nose, or mouth. Germs spread this way.
• Try to avoid close contact with sick people.
• Practice good health habits. Get plenty of sleep and exercise, manage your stress, drink plenty of fluids, and eat healthy food.
• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• If you are sick with flu-like illness, stay home for at least 24 hours after your fever is gone without the use of fever-reducing medicine.