The Swine Flu Epidemic

[Richard B the EMT]

BUREAU OF OPERATIONS

EMS COMMAND ORDER 2009-075

April 25, 2009

SWINE FLU ALERT

NEW CALL TYPES – FEVER & COUGH (FC)

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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

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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

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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

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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).

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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

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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

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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.

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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.

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! 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.

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! 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

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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.

[JPINFV]

http://www.cdc.gov/swineflu/

[ncmedic309]

Just for shits and giggles, if your referring to the NY area alone, I guess it is considered an Epidemic, but in all actuality, it's really a Pandemic.

[Brady]

I thought that more people died from just the regular old flu every year. We have had 6 people in adjacent counties to mine that have been tested. 3 of them have come back negative, but they assure us that the people could have actually had it but gotten the medicine in time to keep it from advancing. We have to deal with west nile virus every year and a few years ago it was horrific, makes the swine flu look like a cuddly bunny.

[Dustdevil]

I dunno about the rest of you suckers, but at least Richard and I don't have to worry about no swine flu!

[celticcare]

The hosptial I work at has already had 10 confirmed cases of Swine Flu. Reached New Zealand already. Be interesting what comes out in the next few days from infection control.

PS - Richard, that was a heap of reading, that is 10 mins of my life I will never get back

[p3medic]

I thought that more people died from just the regular old flu every year. We have had 6 people in adjacent counties to mine that have been tested. 3 of them have come back negative, but they assure us that the people could have actually had it but gotten the medicine in time to keep it from advancing. We have to deal with west nile virus every year and a few years ago it was horrific, makes the swine flu look like a cuddly bunny.

West Nile isn't spread person to person, so despite it being "bad", it is much less likely to effect many people, or spread around the globe.

[ERDoc]

From the CDC for EMS/field providers:

http://www.cdc.gov/swineflu/guidance_ems.htm

and a PSA for your further education:

http://www.youtube.com/watch?v=9iJLpe1tZl8

Edited April 29, 2009 by ERDoc

[tniuqs]

Query:

I read on the extensive NYC precations (agree with celticcare) Richard you owe me 10 minutes as well ...!

Statement:

The influenza viruses are RNA viruses; that is, their genetic material is RNA and not DNA. In this case of Swine Flu Influenza A, quote BEB

So my 2 questions would be:

1- Are this alcohol based hand cleaners effective against this Virus (for that matter any other Virus) ????

My reasoning would be: that since the 70/30 % alcohol sanitizers are aimed at bacteria and using the mechanism of rupturing the cell wall membrane of bacterium ... the nature of a Virus is far different therfore my question.

2- Would these foam water based sanitizers be as effective or better in fact ?

Any experts in virology out there ... or are we just getting the virus drunk and a false sence of security.

cheers

[JPINFV]

Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hands cleaners are also effective.

http://www.cdc.gov/swineflu/