Richard B the EMT

Don't know him, and considering the charges, glad of it.

My grandmother, and my mom, taught me an attitude to not curse routinely, otherwise, how would anyone know you're really upset? If you use curses routinely, there is no shock value when used during times of anger. (Grandmother S, and Momma B, 2 smart ladies, these!)

Slightly different take, here: I was the patient, in the ER/ED, with a needle for IV in my elbow, saline "KVO", no bag or tube attached. The doctor "discharged" me. 10 minutes later, when he looked into the exam room and saw me still there, I had to ask him if he'd forgotten anything, and pointed to the IV needle. Suffice to say, it was another incident witnessed by me of "Palm Smack to Forehead" syndrome!

I note something interesting that the reporter said. This officer was placed on a 2 week suspension WITHOUT PAY! Most times I see any officer, a LEO, FD, EMS, or a Security/Special officer on suspension, it usually reads Paid. However, that could just be the mind think of folks from NYC like myself, to pick up on that sort of thing.

There has to be a crossed wire here, somewhere. What does SNL have to do with the Syracuse shooting?

For those not in the know, REMAC is REgional Medical Advisory Committee, and NYCREMSCO is NYC Regional Emergency Medical Service COuncil.

Just hope you never get this one: Crew: Unit to hospital. OLMC: Go unit. Crew: We're inbound with a 60 year old female in cardiac arrest, CPR in progress, ETA 6 minutes. OLMC: What are the vitals? Unit:? OLMC: Unit, what are the patient's vitals? Unit: I say again, the patient is in arrest, CPR in progress! (Off mic) What's with them? OLMC: I need the patient's vitals. Unit; (off mic) they gotta be kidding. (On mic) Zero over zero, pulse rate zero, resps zero. ETA 5. OLMC: We're setting up for you. Although through the dispatcher, this is pretty much how one call I was involved with happened, with names left out to protect both innocent and guilty

(30 seconds later) (FYI, the FDNY EMS Command has the Dispatcher at EMD advise the hospital of the "note" from the ambulance crews. The crews rarely, if at all, have direct contact with the ER/ED crews while enroute.) *Long backboard, C-Collar, Head Bed **Law Enforcement Officer is riding in with us, as is the crew of Paramedic Ambulance 47 Willie. My partner is driving the 47 Willie vehicle, following us in.

Wow. Correct on the first time! I'm still waiting for the "Paralo Ray" weapon of the "Tom Corbett, Space Cadet" books, or a real "Phaser" set to stun! See you in the audience at the new Star Trek movie, by the way. Remember, a "Trekker" is a fan of the Star Trek shows and/or the movies, and a "Trekkie" is a pubescent girl who wants to have Mr Spock father her baby!

OK, now, a quickie quiz: What is the origin of the name "TASER"? (I'm kind of thinking the young'uns won't know, but I might be wrong)

As always on that topic, I refer anyone interested in working for the FDNY as either an EMT, a Paramedic, or even a Fire Fighter, to hit the link, http://www.nyc.gov/html/fdny/html/home2.shtml We've always had people referred to as "Doc". One was the senior Paramedic on "Third Watch". One was a participant in the (in)famous shootout at the OK Corral, Doc Holliday (wait one: he was a licenced Dentist). Then, again, we have the biggest worry wart of the EMS system, "Mother" Tucker, "The Coz's" character in "Mother, Jugs and Speed".

Uh, from another fan of the show, that's Anthony "Tony" Di Nozzo. He is of Italian ancestry.

I'd be looking for an appointment with the audiologist. You HEAR a hoof PRINT, not a hoof beat? You must have a very loud fingerprint, currently being looked at, and listened to, by the Las Vegas (Nevada, USA) CSI unit of the LVPD. Sorry, I just couldn't resist that! LOL.

Both the chauffeurs for the engine and truck companies of the FDNY, and the ambulance "Motor Vehicle Operators" (read that as the EMT or Paramedic assigned to drive the ambulance that day) of the FDNY EMS Command, are, per departmental published policy, allowed to go, when necessary, no more than 10 MPH above the posted road speeds. NOBODY is allowed to drive faster than 50 MPH, which is the maximum speed posted on any road within the city, in a state that has, on some hi speed roadways outside the city, a posted max of 65 MPH.

Going back to Terri's wish to "ride a star", we now know that the star is the Derby winner, "Mine That Bird".

While I, personally, am not going to take the time to look through all those pages, the posting is still available at www.emtcity.com/index.php?showtopic=14388&hl=whacker for anyone who wants to take the time to find out. Also, last time I checked, ever since I found out what it meant, I still have not seen any Yellow Flags out in front of any buildings. Around the turn of the last century, a yellow flag meant the building, it's contents, and residents, were under quarantine. ************************************************************* By the way, if anyone is interested in getting FEMA updates on the Swine Flu or other disaster information, there's a link for free sign-up at https://service.govdelivery.com/service/sub...e=USDHSFEMA_153

In, I think, the early 1970s, a sniper took up position with high powered rifles, in the Texas Tower. In TV movie reconstruction of the incident, they showed commercial armored trucks driving over GSW victims (high ground clearance vehicles), popping open the rear doors, PD jumping out and grabbing the victims, throwing them inside, and then getting them out of harms way for treatment, or transport to the temporary morgue. Anybody have some similar arrangement with local armored car services?

Wish Central asks for specifications as to which horse you want to jockey at the Kentucky Derby, then the wish is granted. That horse is going to be a star, anyway. I wish my Lady J could get her regular teaching paraprofessional position back, at the New York City Department of Education, instead of this almost nonexistant "posting" of a substitute teaching paraprofessional.

MedicRN, I am not saying that this is the time, but sooner or later, Chicken Little is going to be correct!

Read, skim, or ignore the admittedly extensive posting from 5 separate sources, your free choice. I'm not forcing anyone. I got the information sent to me courtesy New York State Volunteer Ambulance and Rescue Association. This morning, I was told, without confirmation, The next step is, the US closes our borders. I heard on MSNBC Cuba has closed travel between themselves and Mexico. Incidentally, I love pork chops, and bacon, but I'm not going to eat any for a couple of days. I also got this, again courtesy of the NYSVARA: (Fire Department of New York City) I also got this from the Department of Homeland Security.

If there are no PD or FD folks to help with crowd control, ask members of the crowd. I have many times asked crowd members (the curious type, not the angry type, which is an entirely different story) if I could "deputize" them to hold back the rest of the group. Many of them actually feel that they are truly helping, which is exactly what they are doing.

BUREAU OF OPERATIONS EMS COMMAND ORDER 2009-075 April 25, 2009 SWINE FLU ALERT NEW CALL TYPES – FEVER & COUGH (FC) 1 1. GENERAL INFORMATION 1.1 In response to confirmed cases of swine influenza in Mexico, California and Texas, and current probable causes under investigation in New York City, all personnel should be vigilant when responding to calls for patients experiencing flu-like symptoms including fever, cough, sore throat, body aches, headaches, chills and fatigue. 1.2 Swine flu is a respiratory infection caused by Type-A influenza viruses that regularly cause outbreaks of influenza in pigs. People do not normally get swine flu, but human infections can occur. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions. 2. PROCEDURE 2.1 When responding to calls where the call type is followed by the FC suffix, denoting fever, cough and other flu like symptoms, or any call when upon arrival it is determined that the patient is exhibiting symptoms of fever, cough and other flu-like symptoms, FDNY EMS and Voluntary Hospital units shall: 2.1.1 Employ universal infectious disease precautions being sure to utilize gloves and the N95 mask, prior to entering the call location and making contact with the patient(s). 2.1.2 Members shall maintain a supply of N95 masks in the vehicle cab. When transporting symptomatic patients, the driver shall dispose of his/her N95 mask prior to entering the cab. The driver shall don a new N95 prior to re-establishing patient contact at the hospital. 2.1.3 Give the patient a surgical mask or N95 mask to reduce the spread of infectious materials from coughing and/or sneezing. 2.2 Patient assessment and treatment shall be initiated according to Department policy and procedures and REMAC protocols. If indicated, administer high concentration oxygen via non-rebreather mask in place of the surgical or N95 mask. 2.3 Patient interview should include inquiry as to recent travel to Mexico, or contact with someone who has recently traveled to Mexico. The EMTS and Paramedics should also establish if a relationship exists with anyone who attends or has contact with someone who attends St. Francis Preparatory School in Fresh Meadows, Queens, New York. This information shall be passed on to the receiving hospital triage agent. 2.4 All personnel shall wash their hands thoroughly with soap and water following any patient contact. 2.5 There is no special cleaning or decontamination of the ambulance necessary at the conclusion of these assignments. FDNY EMS Command Order 2009-075 April 25, 2009 Swine Flu, New FC Call Types 2 2.6 EMS Officers shall ensure all members are aware of this procedure and monitor assignments to ensure compliance. 3. RELATED PROCEDURES 3.1 Office of Medical Affairs Directive 2004-04, Surgical Masks 3.2 For additional facts about influenza and more information about swine flu, personnel may visit the websites of the New York City Department of Health and the Centers for Disease Control and Prevention. BY ORDER OF THE CHIEF OF EMS COMMAND department of health and human services C enters for Disease Control and Prevention MMWR Dispatch Vol. 58 / April 24, 2009 Morbidity and Mortality Weekly Report www.cdc.gov/mmwr On April 21, 2009, CDC reported that two recent cases of febrile respiratory illness in children in southern California had been caused by infection with genetically similar swine influenza A (H1N1) viruses. The viruses contained a unique combination of gene segments that had not been reported previously among swine or human influenza viruses in the United States or elsewhere (1). Neither child had known contact with pigs, resulting in concern that human-to-human transmission might have occurred. The seasonal influenza vaccine H1N1 strain is thought to be unlikely to provide protection. This report updates the status of the ongoing investigation and provides preliminary details about six additional persons infected by the same strain of swine influenza A (H1N1) virus identified in the previous cases, as of April 24. The six additional cases were reported in San Diego County, California (three cases), Imperial County, California (one case), and Guadalupe County, Texas (two cases). CDC, the California Department of Public Health, and the Texas Department of Health and Human Services are conducting case investigations, monitoring for illness in contacts of the eight patients, and enhancing surveillance to determine the extent of spread of the virus. CDC continues to recommend that any influenza A viruses that cannot be subtyped be sent promptly for testing to CDC. In addition, swine influenza A (H1N1) viruses of the same strain as those in the U.S. patients have been confirmed by CDC among specimens from patients in Mexico. Clinicians should consider swine influenza as well as seasonal influenza virus infections in the differential diagnosis for patients who have febrile respiratory illness and who 1) live in San Diego and Imperial counties, California, or Guadalupe County, Texas, or traveled to these counties or 2) who traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in one of the three U.S. counties or Mexico during the 7 days preceding their illness onset. Case Reports San Diego County, California. On April 9, an adolescent girl aged 16 years and her father aged 54 years went to a San Diego County clinic with acute respiratory illness. The youth had onset of illness on April 5. Her symptoms included fever, cough, headache, and rhinorrhea. The father had onset of illness on April 6 with symptoms that included fever, cough, and rhinorrhea. Both had self-limited illnesses and have recovered. The father had received seasonal influenza vaccine in October 2008; the daughter was unvaccinated. Respiratory specimens were obtained from both, tested in the San Diego County Health Department Laboratory, and found to be positive for influenza A using reverse transcription–polymerase chain reaction (RT-PCR), but could not be further subtyped. Two household contacts of the patients have reported recent mild acute respiratory illnesses; specimens have been collected from these household members for testing. One additional case, in a child residing in San Diego County, was identified on April 24; epidemiologic details regarding this case are pending. Imperial County, California. A woman aged 41 years with an autoimmune illness who resided in Imperial County developed fever, headache, sore throat, diarrhea, vomiting, and myalgias on April 12. She was hospitalized on April 15. She recovered and was discharged on April 22. A respiratory specimen obtained April 16 was found to be influenza A positive by RT-PCR at the San Diego Country Health Department Laboratory, but could not be further subtyped. The woman had not been vaccinated against seasonal influenza viruses during the 2008–09 season. Three household contacts of the woman reported no recent respiratory illness. Guadalupe County, Texas. Two adolescent boys aged 16 years who resided in Guadalupe County near San Antonio were tested for influenza and found to be positive for influenza A on April 15. The youths had become ill with acute respiratory symptoms on April 10 and April 14, respectively, and both had gone to an outpatient clinic for evaluation on Update: Swine Influenza A (H1N1) Infections — California and Texas, April 2009 2 MMWR Dispatch April 24, 2009 Viruses from six of the eight patients have been tested for resistance to antiviral medications. All six have been found resistant to amantadine and rimantidine but sensitive to zanamivir and oseltamivir. Reported by: San Diego County Health and Human Svcs; Imperial County Public Health Dept; California Dept of Public Health. Dallas County Health and Human Svcs; Texas Dept of State Health Svcs. Naval Health Research Center; Navy Medical Center, San Diego, California. Animal and Plant Health Inspection Svc, US Dept of Agriculture. Div of Global Migration and Quarantine, National Center for Preparedness, Detection, and Control of Infectious Diseases; National Center for Zoonotic, Vector-Borne, and Enteric Diseases; Influenza Div, National Center for Infectious and Respiratory Diseases, CDC. Editorial Note: In the United States, novel influenza A virus infections in humans, including swine influenza A (H1N1) infections, have been nationally notifiable conditions since 2007. Recent pandemic influenza preparedness activities have greatly increased the capacity of public health laboratories in the United States to perform RT-PCR for influenza and to subtype influenza A viruses they receive from their routine surveillance, enhancing the ability of U.S. laboratories to identify novel influenza A virus infections. Before the cases described in this ongoing investigation, recent cases of swine influenza in humans reported to CDC occurred in persons who either had exposure to pigs or to a family member with exposure to pigs. Transmission of swine influenza viruses between persons with no pig exposure has been described previously, but that transmission has been limited (2,3). The lack of a known history of pig exposure for any of the patients in the current cases indicates that they acquired infection through contact with other infected persons. The spectrum of illness in the current cases is not yet fully defined. In the eight cases identified to date, six patients had self-limited illnesses and were treated as outpatients. One patient was hospitalized. Previous reports of swine influenza, although in strains different from the one identified in the current cases, mostly included mild upper respiratory illness; but severe lower respiratory illness and death also have been reported (2,3). The extent of spread of the strain of swine influenza virus in this investigation is not known. Ongoing investigations by California and Texas authorities of the two previously reported patients, a boy aged 10 years and a girl aged 9 years, include identification of persons in close contact with the children during the period when they were likely infectious (defined as from 1 day before symptom onset to 7 days after symptom onset). These contacts have included household members, extended family members, clinic staff members who cared for the children, and persons in close contact with the boy during his travel to Texas on April 3. Respiratory specimens are being collected from contacts found to have ongoing illness. April 15. Identification and tracking of the youths’ contacts is under way. Five of the new cases were identified through diagnostic specimens collected by the health-care facility in which the patients were examined, based on clinical suspicion of influenza; information regarding the sixth case is pending. The positive specimens were sent to public health laboratories for further evaluation as part of routine influenza surveillance in the three counties. Outbreaks in Mexico Mexican public health authorities have reported increased levels of respiratory disease, including reports of severe pneumonia cases and deaths, in recent weeks. Most reported disease and outbreaks are reported from central Mexico, but outbreaks and severe respiratory disease cases also have been reported from states along the U.S.-Mexico border. Testing of specimens collected from persons with respiratory disease in Mexico by the CDC laboratory has identified the same strain of swine influenza A (H1N1) as identified in the U.S. cases. However, no clear data are available to assess the link between the increased disease reports in Mexico and the confirmation of swine influenza in a small number of specimens. CDC is assisting public health authorities in Mexico in testing additional specimens and providing epidemiologic support. None of the U.S. patients traveled to Mexico within 7 days of the onset of their illness. Epidemiologic and Laboratory Investigations As of April 24, epidemiologic links identified among the new cases included 1) the household of the father and daughter in San Diego County, and 2) the school attended by the two youths in Guadalupe County. As of April 24, no epidemiologic link between the Texas cases and the California cases had been identified, nor between the three new California cases and the two cases previously reported. No recent exposure to pigs has been identified for any of the seven patients. Close contacts of all patients are being investigated to determine whether person-to-person spread has occurred. Enhanced surveillance for additional cases is ongoing in California and in Texas. Clinicians have been advised to test patients who visit a clinic or hospital with febrile respiratory illness for influenza. Positive samples should be sent to public health laboratories for further characterization. Seasonal influenza activity continues to decline in the United States, including in Texas and California, but remains a cause of influenza-like illness in both areas. Vol. 58 MMWR Dispatch 3 In addition, enhanced surveillance for possible cases is under way in clinics and hospitals in the areas where the patients reside. Similar investigations and enhanced surveillance are now under way in the additional six cases. Clinicians should consider swine influenza infection in the differential diagnosis of patients with febrile respiratory illness and who 1) live in San Diego and Imperial counties, California, or Guadalupe County, Texas, or traveled to these counties or 2) who traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in one of the three U.S. counties or Mexico during the 7 days preceding their illness onset. Any unusual clusters of febrile respiratory illness elsewhere in the United States also should be investigated. Patients who meet these criteria should be tested for influenza, and specimens positive for influenza should be sent to public health laboratories for further characterization. Clinicians who suspect swine influenza virus infections in humans should obtain a nasopharyngeal swab from the patient, place the swab in a viral transport medium, refrigerate the specimen, and then contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory. CDC requests that state public health laboratories promptly send all influenza A specimens that cannot be subtyped to the CDC, Influenza Division, Virus Surveillance and Diagnostics Branch Laboratory. As a precautionary step, CDC is working with other partners to develop a vaccine seed strain specific to these recent swine influenza viruses in humans. As always, persons with febrile respiratory illness should stay home from work or school to avoid spreading infections (including influenza and other respiratory illnesses) to others in their communities. In addition, frequent hand washing can lessen the spread of respiratory illness (5). Interim guidance on infection control, treatment, and chemoprophylaxis for swine influenza is available at http://www.cdc.gov/flu/swine/recommendations.htm. Additional information about swine influenza is available at http://www.cdc.gov/flu/swine/index.htm. References 1. CDC. Swine influenza A (H1N1) infection in two children—Southern California, March–April 2009. MMWR 2009;58:400–2. 2. Myers KP, Olsen CW, Gray GC. Cases of swine influenza in humans: a review of the literature. Clin Infect Dis 2007;44:1084–8. 3. Wells DL, Hopfensperger DJ, Arden NH, et al. Swine influenza virus infections. Transmission from ill pigs to humans at a Wisconsin agricultural fair and subsequent probable person-to-person transmission. JAMA 1991;265:478–81. 4. Newman AP, Reisdorf E, Beinemann J, et al. Human case of swine influenza A (H1N1) triple reassortant virus infection, Wisconsin. Emerg Infect Dis 2008;14:1470–2. 5. Ryan MA, Christian RS, Wohlrabe J. Handwashing and respiratory illness among young adults in military training. Am J Prev Med 2001;21:79–83. DCN: 3.02.21 CFR-D MANUAL, CHAPTER 6 OFFICE OF MEDICAL AFFAIRS DIRECTIVE 2004-04 February 26, 2004 SURGICAL MASKS 1 1. GENERAL INFORMATION 1.1 Effective immediately, the Medical Equipment Unit will begin distribution of surgical masks to all FDNY EMS units and CFR-D companies. Surgical masks are for patient use only and are not a substitute for the N-95 masks used by patient care providers for infectious disease protection. 1.2 Patients suspected of having an infectious disease transmitted by airborne or droplet routes (e.g., viral illness, pneumonia, influenza) will be given surgical masks to reduce the spread of infectious materials from coughing and/or sneezing. 1.3 One box of surgical masks shall be placed on each ambulance and CFR-D company. Ten surgical masks shall be carried in each oxygen bag. 2. PROCEDURE 2.1 When treating a patient with a suspected infectious disease transmitted by airborne or droplet routes, members shall: 2.1.1 Immediately place a surgical mask on the patient, especially if the patient is coughing and/or sneezing. NOTE: If the patient refuses to wear a surgical mask, document the refusal on the ACR/PCR. 2.1.2 Initiate patient assessment and treatment according to Department policy and procedures, and REMAC protocols. 2.1.3 If indicated, administer high concentration oxygen via non-rebreather mask (NRB) in place of using a surgical mask. 3. RELATED PROCEDURES 3.1 Office of Medical Affairs Directive 2003-24, Infectious Respiratory Disease Precautions. BY ORDER OF THE FIRE COMMISSIONER, CHIEF OF DEPARTMENT AND THE OFFICE OF MEDICAL AFFAIRS Categories of urgency levels for NYC DOHMH Broadcast Notification System: Health Alert: conveys the highest level of importance; warrants immediate action or attention Health Advisory: provides important information for a specific incident or situation; may not require immediate action Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action THE CITY OF NEW YORK DEPARTMENT OF HEALTH AND MENTAL HYGIENE Michael R. Bloomberg Thomas R. Frieden, M.D., M.P.H. Mayor Commissioner _______________________________________________________________ nyc.gov/health 2009 New York City Department of Health and Mental Hygiene (NYC DOHMH) Health Alert #10: Swine Influenza • Swine influenza A (H1N1) has been diagnosed in patients in California, Texas, and Mexico. • Cases were first identified when specimens were determined to be positive for influenza A but could not be subtyped. Subsequent subtyping at CDC determined that patients were infected with swine influenza A (H1N1). • DOHMH requests that providers test certain patients for influenza A, and that providers contact DOHMH when influenza A testing is positive so that further testing for the possibility of swine influenza may occur at the Public Health Laboratory. • Additional information on the outbreaks in the US and Mexico, as well as further clinical guidance will be provided as it becomes available. Please distribute to staff in the Departments of Critical Care, Emergency Medicine, Family Practice, Geriatrics, Internal Medicine, Infectious Disease, Infection Control, Pediatrics, Neonatal Units, Nurseries, Pulmonary Medicine and Laboratory Medicine April 24, 2009 Dear Colleagues, As of April 24, 2009, six California residents and two Texas residents have been diagnosed with swine influenza A (H1N1) virus infection. All of these patients have recovered. There are no known common exposures and no known pig exposure; the current pattern in California and Texas suggested human-tohuman transmission has occurred. In addition, Mexico confirmed today that febrile respiratory illness in central Mexico and Mexico City have been confirmed as swine influenza. These cases included some deaths, but more detailed data about the clinical and epidemiologic findings in Mexico are not yet available. The viruses from the initial seven U.S. cases are closely related genetically and contain a unique combination of gene segments that have not previously been reported in the United States or elsewhere; genetic typing of the 8th case is pending. The viruses are susceptible to oseltamivir and zanamivir, but resistant to amantadine and rimantadine. Seasonal human influenza vaccine usually does not protect against swine influenza A H1N1 viruses, which are very different in their antigens from human H1N1 viruses. No cases of swine influenza have been detected in NYC. However, because of concern about likely humanto- human transmission of swine influenza in California, Texas, and Mexico, enhanced citywide influenza surveillance is necessary to identify cases that may occur in NYC. DOHMH requests that providers seeing patients in the following categories test for influenza A using a nasopharyngeal swab and a commercially available rapid test, PCR or immunofluorescence test (e.g., DFA or IFA): (1) hospitalized patients with severe febrile respiratory illness of unknown etiology, or (2) outpatients with influenza-like illness (ILI) who have traveled to California, Texas, or Mexico within the past 7 days 2 If testing for influenza is positive for influenza A, please contact DOHMH to arrange transport of specimens to the Public Health Laboratory for subtyping, with possible further testing to occur at CDC, as warranted.. To report suspected cases of swine influenza and arrange for specimen testing, please call the following: • During regular business hours, call 212-788-9830 and request the Doctor of the Week • At all other times, call the Poison Control Center at 212-764-7667 and request to speak with the Doctor on Call. The DOHMH will provide more detailed guidance on the clinical management, including infection control precautions and management of contacts, for cases that are highly suspected or confirmed to be due to swine influenza A. Additional alerts will be provided as more information becomes available on the outbreaks overseas. As always, we appreciate the cooperation of the medical community in New York City and will update you with further information when it becomes available. Sincerely, Annie Fine Scott A. Harper, MD, MPH, MSc Annie Fine, MD Medical Epidemiologist Medical Director Zoonotic, Influenza, & Vectorborne Diseases Unit Zoonotic, Influenza, & Vectorborne Diseases Unit Bureau of Communicable Disease Bureau of Communicable Disease Categories of urgency levels for NYC DOHMH Broadcast Notification System: Health Alert: conveys the highest level of importance; warrants immediate action or attention Health Advisory: provides important information for a specific incident or situation; may not require immediate action Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action THE CITY OF NEW YORK DEPARTMENT OF HEALTH AND MENTAL HYGIENE Michael R. Bloomberg Thomas R. Frieden, M.D., M.P.H. Mayor Commissioner _______________________________________________________________ nyc.gov/health 2009 New York City Department of Health and Mental Hygiene (NYC DOHMH) Health Alert #11: Swine Influenza Update Please distribute to staff in the Departments of Critical Care, Emergency Medicine, Family Practice, Geriatrics, Internal Medicine, Infectious Disease, Infection Control, Pediatrics, Neonatal Units, Nurseries, Pulmonary Medicine and Laboratory Medicine April 25, 2009 PLEASE NOTE: This is a rapidly evolving situation. This alert provides interim guidance. Guidance is likely to change in the upcoming days and weeks as more information becomes available. • Swine influenza is suspected as the cause of a large outbreak of influenza A at St. Francis Preparatory High School in Queens. Specimens obtained from students at the school have been confirmed as influenza A, and are unsubtypeable as either H1 or H3 at the NYC Public Health Laboratory. This meets the case definition for probable swine influenza (see CDC case definitions below). o To date, all illnesses appear to have been mild and no cases have been hospitalized. o Samples are being sent to CDC tonight to determine if this outbreak is due to swine influenza. Results will be available tomorrow (Sunday). o At this time, we are recommending antiviral treatment with oseltamivir or zanamavir as follows for persons associated with the school: Severe influenza-like illness (ILI) or other severe febrile respiratory illness in a student, teacher, staff, or in any close contacts (e.g., household) of someone who attends or works at the school. For patients with mild illness, treatment is only recommended for people who also have underlying conditions that increase the risk for more severe illness due to influenza (listed below). Mild illness should be treated only if treatment can be started within 48 hours of symptom onset. o At this time, prophylaxis is only being recommended for the following contacts of ill persons associated with the school: Healthcare workers who provided care to ill patients, and who either were not using or had a breach in appropriate personal protection when caring for patients or obtaining specimens Asymptomatic household and other close contacts of ill persons who are at higher risk for complications of influenza (listed below). • Reporting and management of other NYC hospitalized patients with severe, unexplained febrile, respiratory illness: o Immediately report all patients with severe, unexplained febrile respiratory illness to the Provider Access Line at 1-917-438-9766. o Test patients with severe febrile respiratory illness for influenza A using a commercially available rapid test, PCR or immunofluorescence test (e.g., DFA or IFA). 2 o Personal protective measures should be taken by medical personnel caring for or obtaining specimens from patients being tested for influenza or who have suspected, probable or confirmed swine influenza. See http://www.cdc.gov/swineflu/guidelines_infection_control.htm. o If hospitals are not able to conduct initial rapid influenza testing, please contact the DOHMH to arrange for testing for influenza A. • Management of patients with mild influenza-like illness o Patients with mild illness should be encouraged to stay home until 24-48 hours after resolution of symptoms. Patients should be instructed to wash their hands frequently, cough into a tissue or sleeve (not into bare hands or onto another person), dispose of tissues in the trash, and stay home from school or work until 24-48 hours after illness is resolved. o At this time, we are not recommending routine influenza testing and/or antiviral treatment for persons with mild influenza-like illness, unless they meet the usual criteria for empiric influenza treatment based on underlying illnesses that put them at higher risk for complications of any type of influenza. • According to the CDC, vaccination for seasonal influenza is unlikely to be effective for prevention of swine influenza. • Additional information on the outbreaks in the US and Mexico, including NYC, as well as further clinical guidance will be provided as it becomes available. For updated information on the national situation, see http://www.cdc.gov/swineflu/general_info.htm. Dear Colleagues, On April 23, a high school in Queens was noted to have an outbreak of mild febrile respiratory illness that was confirmed last night to be caused by influenza A. Specimens were sent to the NYC Public Health Laboratory and were untypeable for human H1 or H3 strains, meeting the CDC case definition for probable swine influenza. These specimens are being forwarded to CDC today for further testing to determine if these infections are due to swine influenza. Results should be available tomorrow. The high school has approximately 2,700 students, and as of yesterday, 200 children were reported to be ill, mostly with mild influenza-like symptoms (fever, cough, and/or sore throat). None of the cases were severe or required hospitalization. In the United States, there are currently 6 California residents and 2 Texas residents who have been diagnosed with swine influenza A (H1N1) virus infection; all of these patients had mild illness (only one hospitalization) and all have recovered. Isolates from California and Texas have been found to be susceptible to the neuraminidase inhibitors (oseltamivir and zanamavir) but resistant to the adamantanes (amantadine and rimantadine). In addition, there has been an outbreak of respiratory illness in Mexico, which has been confirmed as at least partly due to swine influenza; clinical and epidemiologic details of this outbreak are still pending, but preliminary reports are of thousands of cases and approximately 70 deaths. Surveillance for Swine Influenza in Hospitalized Cases Citywide: The NYC Health Department is now prioritizing its surveillance efforts for swine influenza on identifying potential cases of febrile, respiratory illness in hospitalized patients, in order to rapidly identify and confirm potential cases with more severe illness. Therefore, DOHMH requests that providers seeing patients with acute febrile respiratory illness only test those patients who are either currently hospitalized or are being admitted to the hospital with unexplained febrile respiratory illness. These patients should be tested for influenza using either a commercial rapid test, or direct or indirect immunofluorescence. Patients who test positive for influenza A should be reported to DOHMH and have specimens referred to DOHMH for further testing to determine whether the influenza A can be subtyped. See contact information below. DOHMH will arrange for transportation of clinical specimens to the Public Health Laboratory. See attached instructions for 3 collecting and submitting laboratory diagnostic specimens for swine influenza testing. Nasopharyngeal swabs are the preferred specimens for influenza testing in the current swine influenza context. Management of Persons with Milder Influenza-like Illness At this time, providers assessing patients with mild febrile respiratory illness in clinical settings, including emergency departments, should not test for influenza and should not administer antiviral medications for presumptive therapy, unless patients meet the usual criteria for empiric influenza treatment based on underlying illnesses (listed below) that put them at higher risk for complications of any type of influenza. These patients may be sent home with instructions to stay at home until 24-48 hours after their symptoms resolve and instructed on the importance of hand and respiratory hygiene. Instructions should be given to seek medical care with worsening of symptoms. Infection Control For current recommendations on infection control in medical care facilities, see http://www.cdc.gov/swineflu/guidelines_infection_control.htm. Antiviral Treatment and Prophylaxis Guidelines Swine influenza viruses identified in this outbreak to date have been susceptible to both oseltamivir and zanamivir. Antiviral therapy with one of these agents should be initiated empirically for patients currently hospitalized with severe unexplained febrile respiratory illness, pending testing for swine influenza. See http://www.cdc.gov/swineflu/recommendations.htm for specific guidelines. This document also includes detailed guidance on antiviral prophylaxis. The Health Department requests that providers also immediately report any clusters of influenza-like illness in medical facilities, congregate settings such as long-term care facilities, or schools. To contact the Health Department, including to report suspected cases of swine influenza in hospitalized patients and arrange for specimen testing, please call the Provider Access Line at 1- 917- 438-9766. This number is also available for questions or consultations by providers. As always, we appreciate the cooperation of the medical community in New York City and will update you with further information when it becomes available. Sincerely, Annie Fine Scott A. Harper, MD, MPH, MSc Annie Fine, MD Medical Epidemiologist Medical Director Zoonotic, Influenza, & Vectorborne Diseases Unit Zoonotic, Influenza, & Vectorborne Diseases Unit Bureau of Communicable Disease Bureau of Communicable Disease 4 Definitions of Respiratory Illness 1. Acute respiratory illness Recent onset of at least two of the following: 1. rhinorrhea or nasal congestion 2. sore throat 3. cough 4. fever or feverishness 2. Influenza-like illness: fever >37.8°C (100°F) plus cough or sore throat Case Definitions for Infection with Swine Influenza A (H1N1) Virus 1. A Confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests: 1. real-time RT-PCR 2. viral culture 3. four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies 2. A Probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness with an influenza test that is positive for influenza A, but H1 and H3 negative. 3. A Suspected case of swine influenza A (H1N1) virus infection is defined as: 1. A person with an acute respiratory illness who was a close contact to a confirmed case of swine influenza A (H1N1) virus infection while the case was ill OR 2. A person with an acute respiratory illness with a recent history of contact with an animal with confirmed or suspected swine influenza A (H1N1) virus infection OR 3. A person with an acute respiratory illness who has traveled to an area where there are confirmed cases of swine influenza A (H1N1) Conditions which increase the risk of severe influenza infection • chronic pulmonary, cardiovascular, renal, hepatic, hematological, or metabolic disorders, • immunosuppression, • compromised respiratory function, including conditions which increase the risk for aspiration, • long-term aspirin therapy • pregnancy • age > 65 years • age < 2 years From NYS DoH Richard F. Daines, M.D. Wendy E. Saunders Commissioner Executive Deputy Commissioner April 24, 2009 To: Healthcare Providers, Hospitals, Laboratories, Local Health Departments From: NYSDOH Bureau of Communicable Disease Control and Wadsworth Laboratory HEALTH ADVISORY: SWINE INFLUENZA A (H1N1) INFECTION Please distribute immediately to staff in the Departments of Laboratory Medicine, Critical Care, Emergency Medicine, Family Practice, Internal Medicine, Infectious Disease, Infection Control, Pediatrics, Pulmonary Medicine, and all inpatient and outpatient units. SUMMARY The New York State Department of Health (NYSDOH) is sending this advisory to provide information regarding the ongoing investigation of swine influenza A (H1N1) virus infections being conducted by the Centers for Disease Control and Prevention (CDC). The guidance in this advisory only applies to providers seeing patients outside of New York City. For guidance related to providers seeing patients in New York City, see the New York City Department of Health and Mental Hygiene Advisory at: www.nyc.gov/health/nycmed. This information is based on currently available information, and is interim and subject to change as additional information becomes available. • Swine influenza A (H1N1) has been diagnosed in patients in California, Texas, and Mexico. • Cases were first identified when specimens were determined to be positive for influenza A but could not be subtyped with standard methods. Subsequent subtyping at CDC determined that patients were infected with swine influenza A (H1N1). • For all patients presenting with acute respiratory illness, NYSDOH requests that providers obtain recent travel histories to affected areas and test patients meeting the enhanced surveillance criteria for suspect swine influenza A. Providers should report such cases to their Local Health Department (LHD) to arrange submission of specimens to NYSDOH Wadsworth Center for influenza A testing. • All clinical laboratories should submit all positive influenza A specimens to NYDSOH Wadsworth Center AND if known, indicate whether the specimen is from a patient with history of travel to an affected area or outbreak exposure. • NYSDOH requests that providers report any outbreaks of influenza-like illness to their LHD. • Additional information on the outbreaks in the US and Mexico, as well as further clinical guidance, will be provided as it becomes available. page 1 of 4 BACKGROUND CDC is investigating eight human cases of swine influenza A (H1N1) virus infection that have been identified in San Diego County and Imperial County, California as well as in San Antonio, Texas. In addition, swine influenza A (H1N1) viruses have also been confirmed by CDC from patients in Mexico. Investigations are ongoing to determine the source and extent of the infection. CDC is working with Mexican health officials, the World Health Organization (WHO), state and local officials in California and Texas and other health and animal officials on investigations into these cases. CDC has provided the following interim guidance for this investigation, as detailed on the CDC web site for this investigation: http://www.cdc.gov/flu/swine/investigation.htm. This guidance is current as of 7:00 PM on 4/24/09. ENHANCED SURVEILLANCE CRITERIA Clinicians should consider swine influenza as well as seasonal influenza virus infections in the differential diagnosis for patients who have febrile respiratory illness and who 1) live in San Diego and Imperial Counties, California, or Guadalupe County, Texas, or traveled to these counties or 2) who travelled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in one of the three US counties or Mexico during the 7 days preceding their illness onset. Patients who meet these criteria should be tested for influenza and providers should immediately notify their LHD to coordinate collection and submission of specimens directly to Wadsworth Center. Clinicians who suspect swine influenza virus infections in humans should obtain a nasopharyngeal swab from the patient, place the swab in viral transport medium, refrigerate the specimen (do not freeze), and then contact the LHD. Any unusual clusters of febrile respiratory illness should be reported to the LHD. PATIENTS WITH ACUTE RESPIRATORY ILLNESS WHO DO NOT MEET CURRENT CASE DEFINITION FOR SWINE INFLUENZA Patients who do not meet the travel and exposure criteria defined above with influenza-like illness should have influenza testing conducted via routine mechanisms. INFECTION CONTROL-INTERIM GUIDANCE For interview and assessment of healthy individuals with epidemiologic links to suspect or confirmed cases of swine influenza, follow Standard Precautions. For interview and examination of an ill, suspected case of swine influenza (meeting current case definition outlined in this advisory), providers should wear a fit-tested N95 respirator [if unavailable, wear a medical (surgical) mask]. For collecting respiratory specimens from an ill suspected case of swine influenza, the following is recommended: 1. Personal protective equipment (PPE): fit-tested disposable N95 respirator [if unavailable, wear a medical (surgical mask)], disposable gloves, gown, and goggles. 2. When completed, place all PPE in a biohazard bag for appropriate disposal. page 2 of 4 3. Wash hands thoroughly with soap and water or alcohol-based hand gel. Recommended Infection Control for a hospitalized patient: • Standard, Droplet and Contact precautions for 7 days after illness onset or until symptoms have resolved. • In addition, personnel should wear N95 respirators when entering the patient room. • Use an airborne infection isolation room (AIIR) with negative pressure air handling, if available; otherwise use a single patient room with the door kept closed. • For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling. Recommended PPE for personnel providing clinical care to ill individuals: • Disposable gown, gloves, goggles, N95 respirator. ANTIVIRAL TREATMENT Antiviral treatment for confirmed or suspected ill cases of swine influenza virus infection may include either oseltamivir or zanamavir, with no preference given at this time. Initiate treatment as soon as possible after the onset of symptoms. Recommendations for use of antivirals may change as data on antiviral susceptibilities become available. As such, please refer to the CDC website for the most up-to-date guidance on antiviral treatment at: http://www.cdc.gov/flu/swine/investigation.htm#pa_health. PUBLIC HEALTH NOTIFICATION Clinicians should contact their LHD to report any suspect case meeting the enhanced surveillance criteria. The LHD will involve the NYSDOH Regional Epidemiology Program. Once the LHD and NYSDOH have decided that the suspect case meets the CDC enhanced surveillance criteria, the LHD will give approval to the clinician for the patient specimen to be submitted to the NYSDOH Wadsworth Center for testing. The clinician should complete the NYSDOH Virus Detection History Form (DOH-1795) noting testing is for a suspect case of swine influenza. Also note relevant patient travel history on this form and results of any influenza laboratory testing that has already been performed. Specimens should be shipped refrigerated (not frozen) overnight to Griffin Laboratory. Specific instructions and contact information for providers are available at: http://www.wadsworth.org/divisions/infdis/...llectsubmit.htm. CONTINUING GUIDANCE The NYSDOH will provide updated guidance as additional information and CDC recommendations become available. Updated information will be posted on the CDC website at: http://www.cdc.gov/flu/swine/investigation.htm. page 3 of 4 page 4 of 4 INFORMATION FOR NEW YORKERS ABOUT SWINE FLU CASES IN CALIFORNIA, TEXAS AND MEXICO AS OF 4/24/09 It’s important to remember that ANY information we have right now is based on an evolving situation and could change. We understand that some people may be concerned about cases of swine flu in California, Texas, and Mexico that were caused by a new strain of virus. At this time, no swine flu cases have been identified in New York State. Some people are worried that this may lead to a pandemic. It’s too soon to know whether that will happen. For a flu virus to cause a pandemic it needs to be a brand new strain, produce severe illness, and pass easily from person to person. The eight swine flu cases identified so far in the US have caused only minor illness. CDC is working with officials in Mexico to try to find out more information about the cases that have occurred there. Even though no cases have been reported outside of Mexico, California, or Texas to date, the CDC recommends that people throughout the US stay informed because people who traveled to Mexico, California or Texas might have been exposed and could bring the virus back with them. Updated information will be provided at www.cdc.gov In New York State, we conduct flu surveillance throughout the year. To make sure that we will know quickly if any swine flu cases occur here, we are arranging to prioritize laboratory testing of samples from people who have flu and have traveled to Mexico, California or Texas. We’ll also prioritize testing of samples from people if we suspect an outbreak, for instance, if influenza like illness occurs in a school or a health care setting. Right now there are no recommendations for US travelers to change their plans to travel to California, Texas or Mexico, although CDC encourages people not to travel in airplanes if they think they have the flu. Control of flu in the current situation is the same as for our usual seasonal flu. CDC is recommending general precautions to reduce the spread of flu: Cover your cough and sneeze; Wash your hands frequently; Stay home from work or school if you have influenza like symptoms. If you have symptoms, check with your health care provider. These simple steps are important and will help prevent flu. We encourage people to make a habit of them. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention MMWR Dispatch Vol. 58 / April 24, 2009 Morbidity and Mortality Weekly Report www.cdc.gov/mmwr On April 21, 2009, CDC reported that two recent cases of febrile respiratory illness in children in southern California had been caused by infection with genetically similar swine influenza A (H1N1) viruses. "e viruses contained a unique combination of gene segments that had not been reported previously among swine or human influenza viruses in the United States or elsewhere (1). Neither child had known contact with pigs, resulting in concern that human-to-human transmission might have occurred. "e seasonal influenza vaccine H1N1 strain is thought to be unlikely to provide protection. "is report updates the status of the ongoing investigation and provides preliminary details about six additional persons infected by the same strain of swine influenza A (H1N1) virus identified in the previous cases, as of April 24. "e six additional cases were reported in San Diego County, California (three cases), Imperial County, California (one case), and Guadalupe County, Texas (two cases). CDC, the California Department of Public Health, and the Texas Department of Health and Human Services are conducting case investigations, monitoring for illness in contacts of the eight patients, and enhancing surveillance to determine the extent of spread of the virus. CDC continues to recommend that any influenza A viruses that cannot be subtyped be sent promptly for testing to CDC. In addition, swine influenza A (H1N1) viruses of the same strain as those in the U.S. patients have been confirmed by CDC among specimens from patients in Mexico. Clinicians should consider swine influenza as well as seasonal influenza virus infections in the differential diagnosis for patients who have febrile respiratory illness and who 1) live in San Diego and Imperial counties, California, or Guadalupe County, Texas, or traveled to these counties or 2) who traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in one of the three U.S. counties or Mexico during the 7 days preceding their illness onset. Case Reports San Diego County, California. On April 9, an adolescent girl aged 16 years and her father aged 54 years went to a San Diego County clinic with acute respiratory illness. "e youth had onset of illness on April 5. Her symptoms included fever, cough, headache, and rhinorrhea. "e father had onset of illness on April 6 with symptoms that included fever, cough, and rhinorrhea. Both had self-limited illnesses and have recovered. "e father had received seasonal influenza vaccine in October 2008; the daughter was unvaccinated. Respiratory specimens were obtained from both, tested in the San Diego County Health Department Laboratory, and found to be positive for influenza A using reverse transcription–polymerase chain reaction (RT-PCR), but could not be further subtyped. Two household contacts of the patients have reported recent mild acute respiratory illnesses; specimens have been collected from these household members for testing. One additional case, in a child residing in San Diego County, was identified on April 24; epidemiologic details regarding this case are pending. Imperial County, California. A woman aged 41 years with an autoimmune illness who resided in Imperial County developed fever, headache, sore throat, diarrhea, vomiting, and myalgias on April 12. She was hospitalized on April 15. She recovered and was discharged on April 22. A respiratory specimen obtained April 16 was found to be influenza A positive by RT-PCR at the San Diego Country Health Department Laboratory, but could not be further subtyped. "e woman had not been vaccinated against seasonal influenza viruses during the 2008–09 season. "ree household contacts of the woman reported no recent respiratory illness. Guadalupe County, Texas. Two adolescent boys aged 16 years who resided in Guadalupe County near San Antonio were tested for influenza and found to be positive for influenza A on April 15. "e youths had become ill with acute respiratory symptoms on April 10 and April 14, respectively, and both had gone to an outpatient clinic for evaluation on Update: Swine Influenza A (H1N1) Infections — California and Texas, April 2009 2 MMWR Dispatch April 24, 2009 Viruses from six of the eight patients have been tested for resistance to antiviral medications. All six have been found resistant to amantadine and rimantidine but sensitive to zanamivir and oseltamivir. Reported by: San Diego County Health and Human Svcs; Imperial County Public Health Dept; California Dept of Public Health. Dallas County Health and Human Svcs; Texas Dept of State Health Svcs. Naval Health Research Center; Navy Medical Center, San Diego, California. Animal and Plant Health Inspection Svc, US Dept of Agriculture. Div of Global Migration and Quarantine, National Center for Preparedness, Detection, and Control of Infectious Diseases; National Center for Zoonotic, Vector-Borne, and Enteric Diseases; Influenza Div, National Center for Infectious and Respiratory Diseases, CDC. Editorial Note: In the United States, novel influenza A virus infections in humans, including swine influenza A (H1N1) infections, have been nationally notifiable conditions since 2007. Recent pandemic influenza preparedness activities have greatly increased the capacity of public health laboratories in the United States to perform RT-PCR for influenza and to subtype influenza A viruses they receive from their routine surveillance, enhancing the ability of U.S. laboratories to identify novel influenza A virus infections. Before the cases described in this ongoing investigation, recent cases of swine influenza in humans reported to CDC occurred in persons who either had exposure to pigs or to a family member with exposure to pigs. Transmission of swine influenza viruses between persons with no pig exposure has been described previously, but that transmission has been limited (2,3). "e lack of a known history of pig exposure for any of the patients in the current cases indicates that they acquired infection through contact with other infected persons. "e spectrum of illness in the current cases is not yet fully defined. In the eight cases identified to date, six patients had self-limited illnesses and were treated as outpatients. One patient was hospitalized. Previous reports of swine influenza, although in strains different from the one identified in the current cases, mostly included mild upper respiratory illness; but severe lower respiratory illness and death also have been reported (2,3). "e extent of spread of the strain of swine influenza virus in this investigation is not known. Ongoing investigations by California and Texas authorities of the two previously reported patients, a boy aged 10 years and a girl aged 9 years, include identification of persons in close contact with the children during the period when they were likely infectious (defined as from 1 day before symptom onset to 7 days after symptom onset). "ese contacts have included household members, extended family members, clinic staff members who cared for the children, and persons in close contact with the boy during his travel to Texas on April 3. Respiratory specimens are being collected from contacts found to have ongoing illness. April 15. Identification and tracking of the youths’ contacts is under way. Five of the new cases were identified through diagnostic specimens collected by the health-care facility in which the patients were examined, based on clinical suspicion of influenza; information regarding the sixth case is pending. "e positive specimens were sent to public health laboratories for further evaluation as part of routine influenza surveillance in the three counties. Outbreaks in Mexico Mexican public health authorities have reported increased levels of respiratory disease, including reports of severe pneumonia cases and deaths, in recent weeks. Most reported disease and outbreaks are reported from central Mexico, but outbreaks and severe respiratory disease cases also have been reported from states along the U.S.-Mexico border. Testing of specimens collected from persons with respiratory disease in Mexico by the CDC laboratory has identified the same strain of swine influenza A (H1N1) as identified in the U.S. cases. However, no clear data are available to assess the link between the increased disease reports in Mexico and the confirmation of swine influenza in a small number of specimens. CDC is assisting public health authorities in Mexico in testing additional specimens and providing epidemiologic support. None of the U.S. patients traveled to Mexico within 7 days of the onset of their illness. Epidemiologic and Laboratory Investigations As of April 24, epidemiologic links identified among the new cases included 1) the household of the father and daughter in San Diego County, and 2) the school attended by the two youths in Guadalupe County. As of April 24, no epidemiologic link between the Texas cases and the California cases had been identified, nor between the three new California cases and the two cases previously reported. No recent exposure to pigs has been identified for any of the seven patients. Close contacts of all patients are being investigated to determine whether person-to-person spread has occurred. Enhanced surveillance for additional cases is ongoing in California and in Texas. Clinicians have been advised to test patients who visit a clinic or hospital with febrile respiratory illness for influenza. Positive samples should be sent to public health laboratories for further characterization. Seasonal influenza activity continues to decline in the United States, including in Texas and California, but remains a cause of influenza-like illness in both areas. Vol. 58 MMWR Dispatch 3 In addition, enhanced surveillance for possible cases is under way in clinics and hospitals in the areas where the patients reside. Similar investigations and enhanced surveillance are now under way in the additional six cases. Clinicians should consider swine influenza infection in the differential diagnosis of patients with febrile respiratory illness and who 1) live in San Diego and Imperial counties, California, or Guadalupe County, Texas, or traveled to these counties or 2) who traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in one of the three U.S. counties or Mexico during the 7 days preceding their illness onset. Any unusual clusters of febrile respiratory illness elsewhere in the United States also should be investigated. Patients who meet these criteria should be tested for influenza, and specimens positive for influenza should be sent to public health laboratories for further characterization. Clinicians who suspect swine influenza virus infections in humans should obtain a nasopharyngeal swab from the patient, place the swab in a viral transport medium, refrigerate the specimen, and then contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory. CDC requests that state public health laboratories promptly send all influenza A specimens that cannot be subtyped to the CDC, Influenza Division, Virus Surveillance and Diagnostics Branch Laboratory. As a precautionary step, CDC is working with other partners to develop a vaccine seed strain specific to these recent swine influenza viruses in humans. As always, persons with febrile respiratory illness should stay home from work or school to avoid spreading infections (including influenza and other respiratory illnesses) to others in their communities. In addition, frequent hand washing can lessen the spread of respiratory illness (5). Interim guidance on infection control, treatment, and chemoprophylaxis for swine influenza is available at http://www.cdc.gov/flu/swine/ recommendations.htm. Additional information about swine influenza is available at http://www.cdc.gov/flu/swine/index. htm. References 1. CDC. Swine influenza A (H1N1) infection in two children—Southern California, March–April 2009. MMWR 2009;58:400–2. 2. Myers KP, Olsen CW, Gray GC. Cases of swine influenza in humans: a review of the literature. Clin Infect Dis 2007;44:1084–8. 3. Wells DL, Hopfensperger DJ, Arden NH, et al. Swine influenza virus infections. Transmission from ill pigs to humans at a Wisconsin agricultural fair and subsequent probable person-to-person transmission. JAMA 1991;265:478–81. 4. Newman AP, Reisdorf E, Beinemann J, et al. Human case of swine influenza A (H1N1) triple reassortant virus infection, Wisconsin. Emerg Infect Dis 2008;14:1470–2. 5. Ryan MA, Christian RS, Wohlrabe J. Handwashing and respiratory illness among young adults in military training. Am J Prev Med 2001;21:79–83. Richard F. Daines, M.D. Wendy E. Saunders Commissioner Executive Deputy Commissioner April 25, 2009 To: Healthcare Providers, Hospitals, Laboratories, Local Health Departments From: NYSDOH Bureau of Communicable Disease Control and Wadsworth Laboratory HEALTH ADVISORY: UPDATE #1--SWINE INFLUENZA A (H1N1) INFECTION Please distribute immediately to staff in the Departments of Laboratory Medicine, Critical Care, Emergency Medicine, Family Practice, Internal Medicine, Infectious Disease, Infection Control, Pediatrics, Pulmonary Medicine, and all inpatient and outpatient units. SUMMARY This is an update to the Health Advisory released on 4/24/09. The New York State Department of Health (NYSDOH) is sending this advisory to provide updated information regarding the ongoing investigation of swine influenza A (H1N1) virus infections being conducted by the Centers for Disease Control and Prevention (CDC). The guidance in this advisory only applies to providers seeing patients outside of New York City. For guidance related to providers seeing patients in New York City, see the New York City Department of Health and Mental Hygiene Advisory at: www.nyc.gov/health/nycmed. This interim information is based on currently available information and is subject to change as additional information becomes available. ! Swine influenza A (H1N1) has been diagnosed in patients in California, Texas, Kansas, and Mexico. ! Cases were first identified when specimens were determined to be positive for influenza A but could not be subtyped with standard methods. Subsequent subtyping at CDC determined that patients were infected with swine influenza A (H1N1). ! New York City Department of Health and Mental Hygiene (NYCDOHMH) has reported a cluster of respiratory illness in a private school in New York City. Nine affected students are now considered probable cases of swine influenza A (H1N1) following preliminary viral testing on nose and throat swabs. The specimens have been sent to CDC for confirmatory testing. Results of those tests are expected by the morning of 4/26/09. ! NYSDOH is requesting local health departments (LHDs) to review their Emergency Department syndromic surveillance (ED Serv) reports daily as a method to monitor influenza activity. page 1 of 9 ! For all patients presenting with acute respiratory illness, NYSDOH requests that providers obtain recent travel histories to affected areas and test patients meeting the case definition for suspect swine influenza A (H1N1). ! Hospitals and providers should have a low threshold for contacting their LHD regarding patients who are highly suspicious for swine influenza A (H1N1), especially if the patient(s) is (are) severely ill. ! NYSDOH requests that providers report any outbreaks of influenza-like illness to their LHD immediately. ! Additional information on the outbreaks in the US and Mexico, as well as further clinical guidance, will be provided as it becomes available. BACKGROUND CDC is investigating 11 human cases of swine influenza A (H1N1) virus infection that have been identified in San Diego County and Imperial County, California, San Antonio, Texas, and Dickinson County, Kansas. In addition, swine influenza A (H1N1) viruses have also been confirmed by CDC from patients in Mexico. Investigations are ongoing to determine the source and extent of the infection. CDC is working with Mexican health officials, the World Health Organization (WHO), state and local officials in California, Texas, and Kansas, and other health and animal officials on investigations into these cases. Currently, NYCDOHMH is investigating a cluster of respiratory illness in a private school in New York City. More than 100 of the school’s students were absent several days this week due to fever, sore throats, and other flu-like symptoms. NYCDOHMH has interviewed more than 100 students or their families; all students have had mild symptoms and none have been hospitalized. Some family members have developed similar symptoms, suggesting spread within the family. The NYCDOHMH Public Health Laboratory has completed preliminary viral testing on nose and throat swabs from nine affected students. Eight of the nine tests are positive Type-A Influenza. Because they do not match H1 and H3 human subtypes of Type-A influenza by available testing methods, they are considered probable cases of swine flu. The specimens have been sent to the CDC for confirmatory testing. Results of those tests are expected by the morning of 4/26/09. CDC has provided the following interim guidance for providers, as detailed on the CDC web site for this investigation: http://www.cdc.gov/flu/swine/investigation.htm. This guidance is current as of 9:00 PM on 4/25/09. CASE DEFINITIONS FOR INFECTION WITH SWINE INFLUENZA A (H1N1) VIRUS The CDC has developed the following case definitions for the purpose of investigation of suspected, probable, and confirmed cases of swine influenza A (H1N1) virus infection: 1. A Confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests: 1. real-time RT-PCR 2. viral culture 3. four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies page 2 of 9 2. A Probable case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness with an influenza test that is positive for influenza A, but H1 and H3 negative. 3. A Suspected case of swine influenza A (H1N1) virus infection is defined as: 1. A person with an acute respiratory illness who was a close contact to a confirmed case of swine influenza A (H1N1) virus infection while the case was ill OR 2. A person with an acute respiratory illness with a recent history of contact with an animal with confirmed or suspected swine influenza A (H1N1) virus infection OR 3. A person with an acute respiratory illness who has traveled to an area where there are confirmed or probable cases of swine influenza A (H1N1) **INCLUDING TRAVEL TO NEW YORK CITY Definitions of Respiratory Illness: 1. Acute respiratory illness Recent onset of at least two of the following: 1. rhinorrhea or nasal congestion 2. sore throat 3. cough 4. fever or feverishness 2. Influenza-like illness: fever >37.8°C (100°F) plus cough or sore throat Patients who meet the suspect case definition should be tested for influenza. Clinicians should obtain a nasopharyngeal swab from the patient (following appropriate infection control precautions), place the swab in viral transport medium, refrigerate the specimen (do not freeze), and submit to their clinical laboratory. Only high-priority specimens should be submitted to NYSDOH Wadsworth Center after consultation with local and state health. Please see the detailed guidelines, “Diagnostic Laboratory Testing for Suspected Swine Influenza,” at the end of this advisory. Any unusual clusters of febrile respiratory illness should be reported to the LHD immediately. INTERIM GUIDANCE FOR INFECTION CONTROL For interview and assessment of healthy individuals with epidemiologic links to suspect or confirmed cases of swine influenza, follow Standard Precautions. For interview, assessment, and care of a suspect, probable, or confirmed swine influenza patient (meeting current case definition outlined in this advisory): ! Use an airborne infection isolation room (AIIR) with negative pressure air handling, if available; otherwise use a single patient room with the door kept closed. ! Use Standard, Droplet and Contact precautions for all patient care activities. For hospitalized patients, continue precautions for 7 days after illness onset or until symptoms have resolved. page 3 of 9 ! Personnel should wear N95 respirators (or if unavailable, surgical masks) when entering the patient room, and should don disposable gown, gloves, and goggles if coming within 6 feet of the patient for any reason. ! For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling. Personnel should wear N95 respirators, gowns, gloves, and goggles for the procedure. ! When care is completed, place all personal protective equipment (PPE) in a biohazard bag for appropriate disposal. ! Maintain strict adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. More information can be found at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html. Emergency departments should place signage at the entrances in English and Spanish directing patients with respiratory symptoms to self-identify so that a surgical mask can be immediately placed. Supplies of masks should be available for this purpose. INTERIM GUIDANCE FOR HEALTHCARE WORKERS (HCW) EXPOSED TO SUSPECT SWINE INFLUENZA CASES An ‘exposed healthcare worker’ is a HCW who came within 6 feet (2 meters) of a suspect, probable, or confirmed case of swine influenza A (H1N1) to interview, examine, or collect a nasopharyngeal specimen. Exposed healthcare workers who donned a surgical mask or N95 respirator during contact with the suspect case patient need NOT be offered post exposure prophylaxis. Exposed healthcare workers who did not don any type of mask during contacts with the suspect case patient should be offered post exposure prophylaxis as soon as possible and within 7 days of exposure, according to the CDC guidance below. While it is recommended that HCW don full PPE, including gown, gloves, and eye protection, donning of any or all of these items in the absence of a mask is sufficient exposure to warrant post exposure prophylaxis. Similarly, HCW who did not don any PPE other than a surgical mask or N95 respirator is considered sufficiently protected to not need post exposure prophylaxis. All exposed HCW, independent of PPE worn, should self-monitor for signs and symptoms of respiratory illness and influenza for seven days following exposure. Any HCW displaying symptoms of illness should refrain from work and seek medical evaluation by their personal page 4 of 9 medical provider. HCWs should call ahead to their provider to notify them of the possibility of swine influenza-related illness. INTERIM GUIDANCE FOR ANTIVIRAL TREATMENT-4/25/09 Antiviral treatment for confirmed or suspected ill cases of swine influenza virus infection may include either oseltamivir or zanamavir, with no preference given at this time. Initiate treatment as soon as possible after the onset of symptoms. Recommendations for use of antivirals may change as data on antiviral susceptibilities become available. As such, please refer to the CDC website for the most up-to-date guidance on antiviral treatment at: http://www.cdc.gov/flu/swine/investigation.htm. As of 4/25/09, the current CDC national recommendations for antiviral treatment are as follows: Duration of antiviral chemoprophylaxis is 7 days after the last known exposure to an ill confirmed case of swine influenza A (H1N1) virus infection. Antiviral dosing and schedules recommended for chemoprophylaxis of swine influenza A (H1N1) virus infection are the same as those recommended for seasonal influenza: http://www.cdc.gov/flu/professionals/antiv...table.htm#table Antiviral chemoprophylaxis (pre-exposure or post-exposure) is recommended for the following individuals: 1. Household close contacts who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly) of a confirmed or suspected case. 2. School children who are at high-risk for complications of influenza (persons with certain chronic medical conditions) who had close contact (face-to-face) with a confirmed or suspected case. 3. Travelers to Mexico who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly). 4. Border workers (Mexico) who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly). 5. Health care workers or public health workers who had unprotected close contact with an ill confirmed or probable case of swine influenza A (H1N1) virus infection during the case’s infectious period. Antiviral chemoprophylaxis can be considered for the following: 1. Any health care worker who is at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly) who is working in an area with confirmed swine influenza A (H1N1) cases, and who is caring for patients with any acute febrile respiratory illness. 2. Non-high risk persons who are travelers to Mexico, first responders, or border workers who are working in areas with confirmed cases of swine influenza A (H1N1) virus infection. PUBLIC HEALTH NOTIFICATION Clinicians should contact their LHD to report any suspect case meeting the case definitions. The LHD will involve the NYSDOH Regional Epidemiology Program. Once the LHD and NYSDOH have decided that the suspect case meets the CDC enhanced surveillance criteria, the LHD will give approval to the clinician for the patient specimen to be submitted to the NYSDOH page 5 of 9 Wadsworth Center for testing. The clinician should complete the NYSDOH Virus Detection History Form (DOH-1795) noting testing is for a suspect case of swine influenza. Also note relevant patient travel history on this form and results of any influenza laboratory testing that has already been performed. Specimens should be shipped refrigerated (not frozen) overnight to Griffin Laboratory. Specific instructions and contact information for providers are available at: http://www.wadsworth.org/divisions/infdis/...llectsubmit.htm. CONTINUING GUIDANCE The NYSDOH will provide updated guidance as additional information and CDC recommendations become available. Updated information will be posted on the CDC website at: http://www.cdc.gov/flu/swine/investigation.htm. SWINE INFLUENZA A (H1N1) VIRUS BIOSAFETY GUIDELINES FOR LABORATORY WORKERS This guidance is for laboratory workers who may be processing or performing diagnostic testing, including virus isolation, on specimens from patients with suspected swine influenza A (H1N1) virus infection. At this time the recommended front-line assay is a real-time RT-PCR assay that detects influenza A. If sub-typing assays for H1 and H3 are available, they should also be performed. If the sample is influenza A positive but H1 and H3 negative and therefore not sub-typeable, the sample should be considered as a “probable” case of swine influenza (H1N1). An assay specific for swine influenza A (H1N1) will be available shortly from the CDC and we will provide details as soon as it is available. Diagnostic laboratory work on clinical samples from patients who are suspected cases of swine influenza A (H1N1) virus infection should be conducted in a BSL2 laboratory. All sample manipulations should be done inside a biosafety cabinet (BSC). Viral isolation on clinical specimens from patients who are suspected cases of swine influenza A (H1N1) virus infection should be performed in a BSL2 laboratory with BSL3 practices (enhanced BSL2 conditions) as described below. Additional precautions include: * Recommended Personal Protective Equipment (based on site specific risk assessment ) * Respiratory protection – fit-tested N95 respirator or higher level of protection. * Shoe covers * Closed-front gown * Double gloves * Eye protection (goggles or face shields) Waste * All waste disposal procedures should be followed as outlined in your facility standard laboratory operating procedures. Appropriate disinfectants * 70% Ethanol * 5% Lysol page 6 of 9 * 10% Bleach All personnel should self monitor for fever and any symptoms of swine influenza infection, which include cough, sore throat, vomiting, diarrhea, headache, runny nose, and muscle aches. Any illness should be reported to your supervisor immediately. For personnel who had unprotected exposure or a known breach in personal protective equipment to clinical material or live virus from a confirmed case of swine influenza A (H1N1), antiviral chemoprophylaxis with zanamivir or oseltamivir for 7 days after exposure can be considered. page 7 of 9 Diagnostic Laboratory Testing for Suspected Swine Influenza ! Collect one nasopharyngeal swab or nasopharyngeal aspirate or nasopharyngeal wash, for submission to the Wadsworth Center for molecular testing. Note: preferred specimen is nasopharyngeal swab in viral transport medium. Use Dacron or rayon swabs with a finetip flexible metal shaft swab, or NP-flocked swab with flexible plastic shaft, for nasopharyngeal swab. Do not use calcium alginate or wooden-shafted swabs. Place swab in sterile vial containing 2ml of viral transport medium. Keep sample cold (4ºC) after collection. Collection Guidelines: o Nasopharyngeal swab: Use a swab with a fine, flexible metal shaft and Dacron or rayon tip, or a flocked swab with long, flexible, plastic shaft, specific for nasopharyngeal swab sample collection. Insert swab into posterior nasopharynx. Rub swab against mucosal surface and leave in place for 5 seconds to absorb secretions. Collection of specimens from both nostrils increases amount of material available for analysis. Place swab in a vial of viral transport medium. Use scissors to cut metal shaft, or snap plastic shaft of flocked swab, so that top of vial can be screwed on tightly. o Nasopharyngeal aspirate: Requires source of suction (syringe, vacuum pump, or wall suction), specimen trap with two outlets, and catheter (no. 6 to 14 depending on size of patient). Without applying suction, insert catheter through nose into posterior nasopharynx (approximately the distance from tip of the nose to the external opening of the ear when measured in a straight line). Apply gentle suction, leaving catheter in place for a few seconds, then withdraw slowly. Suction contents of a vial of viral transport medium or non-bacteriostatic saline through catheter tubing to assist in moving material from tubing into trap and to add viral transport media to specimen. Transfer specimen to a screw cap tube for transport to laboratory. o Nasopharyngeal wash: Use rubber bulb (1-2oz for infants) or syringe to instill 3-5 ml of non-bacteriostatic saline into one nostril while occluding the other. If patient is able to co-operate, instruct them to close glottis by making a humming sound with mouth open. If a rubber bulb is used, release pressure on bulb to allow saline and mucus to enter bulb. Remove from nose and squeeze into vial of transport media. If syringe is used, apply suction to syringe to recover saline and nasal secretions. Alternately, hold sterile container such as urine cup under patient’s nose and ask patient to expel material into it. In either case, add recovered saline-nasal secretions to a vial of viral transport media. ! Results of testing of initial cases suggest that rapid EIA influenza tests may be insensitive for the detection of swine influenza A (H1N1) and these assays should not be relied on as screening tests for this agent. However, a rapid influenza antigen detection test may be performed on the nasopharyngeal/oropharyngeal sample using standard BSL2 work practices in a Class II biological safety cabinet. Regardless of the result, specimens should still be referred to the Wadsworth Center for further testing. page 8 of 9 page 9 of 9 ! Submit a completed Virus Reference and Surveillance Laboratory patient history form (Appendix 2-D) with the specimens. The form is also available on the HPN and HIN at: https://commerce.health.state.ny.us/hpn/han...historyform.pdf ! Viral culture may be performed on respiratory specimens from patients suspected of having swine influenza A (H1N1) infection, who meet the surveillance criteria as described in the advisory update. All specimen manipulutions and viral culture procedures should be performed under BSL2 containment with enhancements as described in the laboratory safety guidelines. ! It is essential that specimens be sent to the Viral Reference and Surveillance Laboratory at the Wadsworth Center as soon as possible after collection. If shipped within two days of collection, store at 4ºC post-collection and ship with cold packs to maintain temperature at 4ºC. Do not use wet ice. If shipment is delayed >2days, then the specimens should be stored frozen at -70ºC and shipped on dry ice. ! It is the shipper’s responsibility to ensure that appropriate shipping materials are used. Please contact your carrier for shipping and packaging information. Patient specimens must be shipped as “Diagnostic Specimens.” All specimens must be shipped "Priority Overnight" and received within 24 hours via chosen carrier. Specimens should ONLY be shipped Sunday - Thursday so that appropriate laboratory personnel can be present to accept and accession specimens Monday - Friday. Address for courier shipping: Wadsworth Center, NYSDOH Griffin Laboratory Virus Reference and Surveillance Laboratory 5668 State Farm Road (Rt. 155) Slingerlands, NY 12159 All information above from: The FDNY EMS Command, FDNY Office of Medical Affairs, New York City Department of Health and Mental Hygiene, New York State Department of Health, Centers For Disease Control.

Wish Central advises they cannot grant that wish. EMS and Normal Sane Lives are utterly incompatible! I wish afib some Tylenol 3 for the headache from being hit by that anvil.

You're all sick! Funny, but sick! Post the video when you get back, please?

The "Hand Drop Over Face" technique I've heard of, not so the alcohol up the nose. Besides, as I'm BLS, per protocols, I don't have access to a syringe. New York State DoH outlawed "Ammonia Inhalants", sometimes called "Snappers", over 30 years ago. Does anyone have them still included in local protocols? Please give the area/country, if you do, just for my own interest and curiosity.