~General Information~

General Information



|What is swine flu?|

What is swine flu?

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and do happen. Swine flu viruses have been reported to spread from person-to-person, but in the past, this transmission was limited and not sustained beyond three people.





|Are there human infections with swine flu in the U.S.?|

Are there human infections with swine flu in the U.S.?

In late March and early April 2009, cases of human infection with swine influenza A (H1N1) viruses were first reported in Southern California and near Guadalupe County, Texas. Other U.S. states have reported cases of swine flu infection in humans and cases have been reported internationally as well. An updated case count of confirmed swine flu infections in the United States is kept at http://www.cdc.gov/swineflu/investigation.htm CDC and local and state health agencies are working together to investigate this situation.





|Is this swine flu virus contagious?|

Is this swine flu virus contagious?

CDC has determined that this swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it is not known how easily the virus spreads between people.



|What are the symptoms?|

What are the symptoms?

The symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.





|How does it spread?|

How does it spread?

Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.





|Can I get it from eating or preparing pork?|

Can I get it from eating or preparing pork?



No. Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork products is safe.





|How can someone with the flu infect someone else?|

Can I get it from eating or preparing pork?



Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or more days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.





|What should I do to keep from getting the flu?|

What should I do to keep from getting the flu?

First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.





|Are there medicines to treat swine flu?|

Are there medicines to treat swine flu?



Yes. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with these swine influenza viruses. Antiviral drugs are prescription medicines (pills, liquid or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms).





|How long can an infected person spread swine flu to others?|

How long can an infected person spread swine flu to others?



People with swine influenza virus infection should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children, especially younger children, might potentially be contagious for longer periods.





|What surfaces are most likely to be sources of contamination?|

What surfaces are most likely to be sources of contamination?



Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk and then touches their own eyes, mouth or nose before washing their hands.





|How long can viruses live outside the body?|

How long can viruses live outside the body?



We know that some viruses and bacteria can live 2 hours or longer on surfaces like cafeteria tables, doorknobs, and desks. Frequent handwashing will help you reduce the chance of getting contamination from these common surfaces.





|What can I do to protect myself from getting sick?|

What can I do to protect myself from getting sick?



There is no vaccine available right now to protect against swine flu. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these everyday steps to protect your health:



* Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

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

* Avoid touching your eyes, nose or mouth. Germs spread this way.

* Try to avoid close contact with sick people.

* If you get sick with influenza, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.





|What is the best way to keep from spreading the virus through coughing or sneezing?|

What is the best way to keep from spreading the virus through coughing or sneezing?



If you are sick, limit your contact with other people as much as possible. Do not go to work or school if ill. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Put your used tissue in the waste basket. Cover your cough or sneeze if you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze.





|What is the best technique for washing my hands to avoid getting the flu?|

What is the best technique for washing my hands to avoid getting the flu?



Washing your hands often will help protect you from germs. Wash with soap and water or clean with alcohol-based hand cleaner. We recommend that when you wash your hands -- with soap and warm water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.





|What should I do if I get sick?|

What should I do if I get sick?



If you live in areas where swine influenza cases have been identified and become ill with influenza-like symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea, you may want to contact their health care provider, particularly if you are worried about your symptoms. Your health care provider will determine whether influenza testing or treatment is needed.



If you are sick, you should stay home and avoid contact with other people as much as possible to keep from spreading your illness to others.



If you become ill and experience any of the following warning signs, seek emergency medical care.



In children emergency warning signs that need urgent medical attention include:



* Fast breathing or trouble breathing

* Bluish skin color

* Not drinking enough fluids

* Not waking up or not interacting

* Being so irritable that the child does not want to be held

* Flu-like symptoms improve but then return with fever and worse cough

* Fever with a rash



In adults, emergency warning signs that need urgent medical attention include:



* Difficulty breathing or shortness of breath

* Pain or pressure in the chest or abdomen

* Sudden dizziness

* Confusion

* Severe or persistent vomiting







|How serious is swine flu infection?|

How serious is swine flu infection?



Like seasonal flu, swine flu in humans can vary in severity from mild to severe. Between 2005 until January 2009, 12 human cases of swine flu were detected in the U.S. with no deaths occurring. However, swine flu infection can be serious. In September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu and died 8 days later. A swine flu outbreak in Fort Dix, New Jersey occurred in 1976 that caused more than 200 cases with serious illness in several people and one death.





|What is CDC doing in response to the outbreak?|

What is CDC doing in response to the outbreak?



CDC has implemented its emergency response. The agency's goals are to reduce transmission and illness severity, and provide information to help health care providers, public health officials and the public address the challenges posed by the new virus. CDC continues to issue new interim guidance for clinicians and public health professionals. In addition, CDC's Division of the Strategic National Stockpile (SNS) continues to send antiviral drugs, personal protective equipment, and respiratory protection devices to all 50 states and U.S. territories to help them respond to the outbreak.



|What epidemiological investigations are taking place in response to the recent outbreak?|

What epidemiological investigations are taking place in response to the recent outbreak?



CDC works very closely with state and local officials in areas where human cases of H1N1 (swine flu) infections have been identified. In California and Texas, where EpiAid teams have been deployed, many epidemiological activities are taking place or planned including:



* Active surveillance in the counties where infections in humans have been identified;

* Studies of health care workers who were exposed to patients infected with the virus to see if they became infected;

* Studies of households and other contacts of people who were confirmed to have been infected to see if they became infected;

* Study of a public high school where three confirmed human cases of influenza A (H1N1) of swine origin occurred to see if anyone became infected and how much contact they had with a confirmed case; and

* Study to see how long a person with the virus infection sheds the virus.

---------------------------------------------------------------------------------------------------------------------------





~Key Facts~

Key Facts



Swine Flu

|What is Swine Influenza?|

What is Swine Influenza?



Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza virus that regularly causes outbreaks of influenza in pigs. Swine flu viruses cause high levels of illness and low death rates in pigs. Swine influenza viruses may circulate among swine throughout the year, but most outbreaks occur during the late fall and winter months similar to outbreaks in humans. The classical swine flu virus (an influenza type A H1N1 virus) was first isolated from a pig in 1930.



|How many swine flu viruses are there?|

How many swine flu viruses are there?

Like all influenza viruses, swine flu viruses change constantly. Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses. When influenza viruses from different species infect pigs, the viruses can reassort (i.e. swap genes) and new viruses that are a mix of swine, human and/or avian influenza viruses can emerge. Over the years, different variations of swine flu viruses have emerged. At this time, there are four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. However, most of the recently isolated influenza viruses from pigs have been H1N1 viruses.



Swine Flu in Humans



|Can humans catch swine flu?|

Can humans catch swine flu?



Swine flu viruses do not normally infect humans. However, sporadic human infections with swine flu have occurred. Most commonly, these cases occur in persons with direct exposure to pigs (e.g. children near pigs at a fair or workers in the swine industry). In addition, there have been documented cases of one person spreading swine flu to others. For example, an outbreak of apparent swine flu infection in pigs in Wisconsin in 1988 resulted in multiple human infections, and, although no community outbreak resulted, there was antibody evidence of virus transmission from the patient to health care workers who had close contact with the patient.



|How common is swine flu infection in humans?|

How common is swine flu infection in humans?

In the past, CDC received reports of approximately one human swine influenza virus infection every one to two years in the U.S., but from December 2005 through February 2009, 12 cases of human infection with swine influenza have been reported.



|What are the symptoms of swine flu in humans?|

What are the symptoms of swine flu in humans?

The symptoms of swine flu in people are expected to be similar to the symptoms of regular human seasonal influenza and include fever, lethargy, lack of appetite and coughing. Some people with swine flu also have reported runny nose, sore throat, nausea, vomiting and diarrhea.



|Can people catch swine flu from eating pork?|

Can people catch swine flu from eating pork?

No. Swine influenza viruses are not transmitted by food. You can not get swine influenza from eating pork or pork products. Eating properly handled and cooked pork and pork products is safe. Cooking pork to an internal temperature of 160øF kills the swine flu virus as it does other bacteria and viruses.



|How does swine flu spread?|

How does swine flu spread?



Influenza viruses can be directly transmitted from pigs to people and from people to pigs. Human infection with flu viruses from pigs are most likely to occur when people are in close proximity to infected pigs, such as in pig barns and livestock exhibits housing pigs at fairs. Human-to-human transmission of swine flu can also occur. This is thought to occur in the same way as seasonal flu occurs in people, which is mainly person-to-person transmission through coughing or sneezing of people infected with the influenza virus. People may become infected by touching something with flu viruses on it and then touching their mouth or nose.



|What do we know about human-to-human spread of swine flu?|

What do we know about human-to-human spread of swine flu?



In September 1988, a previously healthy 32-year-old pregnant woman was hospitalized for pneumonia and died 8 days later. A swine H1N1 flu virus was detected. Four days before getting sick, the patient visited a county fair swine exhibition where there was widespread influenza-like illness among the swine.



In follow-up studies, 76% of swine exhibitors tested had antibody evidence of swine flu infection but no serious illnesses were detected among this group. Additional studies suggest that one to three health care personnel who had contact with the patient developed mild influenza-like illnesses with antibody evidence of swine flu infection.

How can human infections with swine influenza be diagnosed?

To diagnose swine influenza A infection, a respiratory specimen would generally need to be collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding virus). However, some persons, especially children, may shed virus for 10 days or longer. Identification as a swine flu influenza A virus requires sending the specimen to CDC for laboratory testing.



|What medications are available to treat swine flu infections in humans?|

What medications are available to treat swine flu infections in humans?



There are four different antiviral drugs that are licensed for use in the US for the treatment of influenza: amantadine, rimantadine, oseltamivir and zanamivir. While most swine influenza viruses have been susceptible to all four drugs, the most recent swine influenza viruses isolated from humans are resistant to amantadine and rimantadine. At this time, CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with swine influenza viruses.



|What other examples of swine flu outbreaks are there?|

What other examples of swine flu outbreaks are there?



Probably the most well known is an outbreak of swine flu among soldiers in Fort Dix, New Jersey in 1976. The virus caused disease with x-ray evidence of pneumonia in at least 4 soldiers and 1 death; all of these patients had previously been healthy. The virus was transmitted to close contacts in a basic training environment, with limited transmission outside the basic training group. The virus is thought to have circulated for a month and disappeared. The source of the virus, the exact time of its introduction into Fort Dix, and factors limiting its spread and duration are unknown. The Fort Dix outbreak may have been caused by introduction of an animal virus into a stressed human population in close contact in crowded facilities during the winter. The swine influenza A virus collected from a Fort Dix soldier was named A/New Jersey/76 (Hsw1N1).

Is the H1N1 swine flu virus the same as human H1N1 viruses?

No. The H1N1 swine flu viruses are antigenically very different from human H1N1 viruses and, therefore, vaccines for human seasonal flu would not provide protection from H1N1 swine flu viruses.



Swine Flu in Pigs



|How does swine flu spread among pigs?|

How does swine flu spread among pigs?

Swine flu viruses are thought to be spread mostly through close contact among pigs and possibly from contaminated objects moving between infected and uninfected pigs. Herds with continuous swine flu infections and herds that are vaccinated against swine flu may have sporadic disease, or may show only mild or no symptoms of infection.



|What are signs of swine flu in pigs?|

What are signs of swine flu in pigs?

Signs of swine flu in pigs can include sudden onset of fever, depression, coughing (barking), discharge from the nose or eyes, sneezing, breathing difficulties, eye redness or inflammation, and going off feed.



|How common is swine flu among pigs?|

How common is swine flu among pigs?

H1N1 and H3N2 swine flu viruses are endemic among pig populations in the United States and something that the industry deals with routinely. Outbreaks among pigs normally occur in colder weather months (late fall and winter) and sometimes with the introduction of new pigs into susceptible herds. Studies have shown that the swine flu H1N1 is common throughout pig populations worldwide, with 25 percent of animals showing antibody evidence of infection. In the U.S. studies have shown that 30 percent of the pig population has antibody evidence of having had H1N1 infection. More specifically, 51 percent of pigs in the north-central U.S. have been shown to have antibody evidence of infection with swine H1N1. Human infections with swine flu H1N1 viruses are rare. There is currently no way to differentiate antibody produced in response to flu vaccination in pigs from antibody made in response to pig infections with swine H1N1 influenza.



While H1N1 swine viruses have been known to circulate among pig populations since at least 1930, H3N2 influenza viruses did not begin circulating among US pigs until 1998. The H3N2 viruses initially were introduced into the pig population from humans. The current swine flu H3N2 viruses are closely related to human H3N2 viruses.



|Is there a vaccine for swine flu?|

Is there a vaccine for swine flu?

Vaccines are available to be given to pigs to prevent swine influenza. There is no vaccine to protect humans from swine flu. The seasonal influenza vaccine will likely help provide partial protection against swine H3N2, but not swine H1N1 viruses.

--------------------------------------------------------------------------------------------------------------------------- 



~Investigations~

Investigations 



Interim Guidance on Case Definitions to be Used For Investigations of Swine-Origin Influenza A (H1N1) Cases*



This document provides interim guidance for state and local health departments conducting investigations of human cases of swine-origin influenza A (H1N1) virus (S-OIV). The following case definitions are for the purpose of investigations of suspected, probable, and confirmed cases of S-OIV infection.



Acute febrile respiratory illness is defined as a measured temperature 100 degrees Fahrenheit and recent onset of at least one of the following: rhinorrhea or nasal congestion, sore throat, or cough.



Case Definitions for Infection with Swine-origin Influenza A (H1N1) Virus (S-OIV)



A confirmed case of S-OIV infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests:



1. real-time RT-PCR

2. viral culture



A probable case of S-OIV infection is defined as a person with an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR



A suspected case of S-OIV infection is defined as a person with acute febrile respiratory illness with onset



* within 7 days of close contact with a person who is a confirmed case of S-OIV infection, or

* within 7 days of travel to community either within the United States or internationally where there are one or more confirmed cases of S-OIV infection, or

* resides in a community where there are one or more confirmed cases of S-OIV infection.



---------------------------------------------------------------------------------------------------------------------------



~Antiviral Drugs and Swine Influenza Antiviral Drugs~

Antiviral Drugs and Swine Influenza Antiviral Drugs



Antiviral drugs are prescription medicines (pills, liquid or an inhaler) with activity against influenza viruses, including swine influenza viruses. Antiviral drugs can be used to treat swine flu or to prevent infection with swine flu viruses. These medications must be prescribed by a health care professional. Influenza antiviral drugs only work against influenza viruses -- they will not help treat or prevent symptoms caused by infection from other viruses that can cause symptoms similar to the flu.



There are four influenza antiviral drugs approved for use in the United States (oseltamivir, zanamivir, amantadine and rimantadine). The swine influenza A (H1N1) viruses that have been detected in humans in the United States and Mexico are resistant to amantadine and rimantadine so these drugs will not work against these swine influenza viruses. Laboratory testing on these swine influenza A (H1N1) viruses so far indicate that they are susceptible (sensitive) to oseltamivir and zanamivir.



|Benefits of Antiviral Drugs|

Benefits of Antiviral Drugs



Treatment: If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious influenza complications. Influenza antiviral drugs work best when started soon after illness onset (within two 2 days), but treatment with antiviral drugs should still be considered after 48 hours of symptom onset, particularly for hospitalized patients or people at high risk for influenza-related complications.



Prevention: Influenza antiviral drugs also can be used to prevent influenza when they are given to a person who is not ill, but who has been or may be near a person with swine influenza. When used to prevent the flu, antiviral drugs are about 70% to 90% effective. When used for prevention, the number of days that they should be used will vary depending on a person's particular situation.



|CDC Recommendation|

CDC Recommendation



CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with swine influenza viruses.



* Oseltamivir (brand name Tamiflu r) is approved to both treat and prevent influenza A and B virus infection in people one year of age and older.

* Zanamivir (brand name Relenza r) is approved to treat influenza A and B virus infection in people 7 years and older and to prevent influenza A and B virus infection in people 5 years and older.



Recommendations for using antiviral drugs for treatment or prevention of swine influenza will change as we learn more about this new virus.



Clinicians should consider treating any person with confirmed or suspected swine influenza with an antiviral drug. Visit: http://www.cdc.gov/swineflu/recommendations.htm for specific recommendations.



---------------------------------------------------------------------------------------------------------------------------



~Treatment Taking Care of a Sick Person in Your Home~

Treatment Taking Care of a Sick Person in Your Home



Swine influenza A virus infection (swine flu) can cause a wide range of symptoms, including fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. People with swine flu also can have vomiting and diarrhea. Like seasonal flu, swine flu in humans can vary in severity from mild to severe.Severe disease with pneumonia, respiratory failure and even death is possible with swine flu infection. Certain groups might be more likely to develop a severe illness from swine flu infection, such as persons with chronic medical conditions. Sometimes bacterial infections may occur at the same time as or after infection with influenza viruses and lead to pneumonias, ear infections, or sinus infections.



The following information can help you provide safer care at home for sick persons during a flu pandemic.



|How Flu Spreads|

How Flu Spreads



The main way that influenza viruses are thought to spread is from person to person in respiratory droplets of coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose of people nearby. Influenza viruses may also be spread when a person touches respiratory droplets on another person or an object and then touches their own mouth or nose (or someone else's mouth or nose) before washing their hands.



|People with swine flu who are cared for at home should:|

People with swine flu who are cared for at home should:



* check with their health care provider about any special care they might need if they are pregnant or have a health condition such as diabetes, heart disease, asthma, or emphysema

* check with their health care provider about whether they should take antiviral medications

* stay home for 7 days after the start of illness and fever is gone

* get plenty of rest

* drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to keep from being dehydrated

* cover coughs and sneezes. Clean hands with soap and water or an alcohol-based hand rub often and especially after using tissues and after coughing or sneezing into hands.

* avoid close contact with others - do not go to work or school while ill

* be watchful for emergency warning signs (see below) that might indicate you need to seek medical attention



|Medications to Help Lessen Symptoms of the Flu|

Medications to Help Lessen Symptoms of the Flu



Check with your healthcare provider or pharmacist for correct, safe use of medications



Antiviral medications can sometimes help lessen influenza symptoms, but require a prescription. Most people do not need these antiviral drugs to fully recover from the flu. However, persons at higher risk for severe flu complications, or those with severe flu illness who require hospitalization, might benefit from antiviral medications. Antiviral medications are available for persons 1 year of age and older. Ask your healthcare provider whether you need antiviral medication.



Influenza infections can lead to or occur with bacterial infections. Therefore, some people will also need to take antibiotics. More severe or prolonged illness or illness that seems to get better, but then gets worse again may be an indication that a person has a bacterial infection. Check with your healthcare provider if you have concerns.



Warning! Do not give aspirin (acetylsalicylic acid) to children or teenagers who have the flu; this can cause a rare but serious illness called Reye's syndrome. For more information about Reye's syndrome, visit the National Institute of Health website at http://www.ninds.nih.gov/disorders/reyes_syndrome/reyes_syndrome.htm



* Check ingredient labels on over-the-counter cold and flu medications to see if they contain aspirin.

* Teenagers with the flu can take medicines without aspirin, such as acetaminophen (Tylenolr) and ibuprofen (Advilr, Motrinr, Nuprinr), to relieve symptoms.

* Children younger than 2 years of age should not be given over-the-counter cold medications without first speaking with a healthcare provider.

* The safest care for flu symptoms in children younger than 2 years of age is using a cool-mist humidifier and a suction bulb to help clear away mucus.

* Fevers and aches can be treated with acetaminophen (Tylenolr) or ibuprofen (Advilr, Motrinr, Nuprinr) or nonsteroidal anti-inflammatory drugs (NSAIDS). Examples of these kinds of medications include:



Generic Name Brand Name(s)



Acetaminophen 



Tylenolr



Ibuprofen





Advilr, Motrinr, Nuprinr



Naproxen





Aleve



* Over-the-counter cold and flu medications used according to the package instructions may help lessen some symptoms such as cough and congestion. Importantly, these medications will not lessen how infectious a person is.

* Check the ingredients on the package label to see if the medication already contains acetaminophen or ibuprofen before taking additional doses of these medications-don't double dose! Patients with kidney disease or stomach problems should check with their health care provider before taking any NSAIDS.



Check with your health care provider or pharmacist if you are taking other over-the-counter or prescription medications not related to the flu



|When to Seek Emergency Medical Care|

When to Seek Emergency Medical Care



Get medical care right away if the sick person at home:



* has difficulty breathing or chest pain

* has purple or blue discoloration of the lips

* is vomiting and unable to keep liquids down

* has signs of dehydration such as dizziness when standing, absence of urination, or in infants, a lack of tears when they cry

* has seizures (for example, uncontrolled convulsions)

* is less responsive than normal or becomes confused



|Steps to Lessen the Spread of Flu in the Home|

Steps to Lessen the Spread of Flu in the Home



When providing care to a household member who is sick with influenza, the most important ways to protect yourself and others who are not sick are to:



* keep the sick person away from other people as much as possible (see "placement of the sick person at home")

* remind the sick person to cover their coughs, and clean their hands with soap and water or an alcohol-based hand rub often, especially after coughing and/or sneezing.

* have everyone in the household clean their hands often, using soap and water or an alcohol-based hand rub

* ask your healthcare provider if household contacts of the sick person-particularly those contacts who may have chronic health conditions-should take antiviral medications such as oseltamivir (Tamiflur) or zanamivir (Relenzar) to prevent the flu.



|Placement of the sick person|

Placement of the sick person



* Keep the sick person in a room separate from the common areas of the house. (For example, a spare bedroom with its own bathroom, if that's possible.) Keep the sickroom door closed.

* Unless necessary for medical care, persons with the flu should not leave the home when they have a fever or during the time that they are most likely to spread their infection to others (7 days after onset of symptoms in adults. Children may pass the virus for longer than 7 days).

* If persons with the flu need to leave the home (for example, for medical care), they should cover their nose and mouth when coughing or sneezing and wear a loose-fitting (surgical) mask if available.

* Have the sick person wear a surgical mask if they need to be in a common area of the house near other persons.

* If possible, sick persons should use a separate bathroom. This bathroom should be cleaned daily with household disinfectant (see below).



|Protect other persons in the home|

Protect other persons in the home



* The sick person should not have visitors other than caregivers. A phone call is safer than a visit.

* If possible, have only one adult in the home take care of the sick person.

* Avoid having pregnant women care for the sick person. (Pregnant women are at increased risk of influenza-related complications and immunity can be suppressed during pregnancy).

* All persons in the household should clean their hands with soap and water or an alcohol-based hand rub frequently, including after every contact with the sick person or the person's room or bathroom.

* Use paper towels for drying hands after hand washing or dedicate cloth towels to each person in the household. For example, have different colored towels for each person.

* If possible, consideration should be given to maintaining good ventilation in shared household areas (e.g., keeping windows open in restrooms, kitchen, bathroom, etc.).

* Antivirals can be used to prevent the flu, so check with your healthcare provider to see if some persons in the home should use antiviral medications.



|If you are the caregiver|

If you are the caregiver



* Avoid being face-to-face with the sick person.

* When holding small children who are sick, place their chin on your shoulder so that they will not cough in your face.

* Clean your hands with soap and water or use an alcohol-based hand rub after you touch the sick person or handle used tissues, or laundry.

* Caregivers might catch flu from the person they are caring for and then the caregiver might be able to spread the flu to others before the caregiver shows symptoms. Therefore, the caregiver should wear a mask when they leave their home to keep from spreading flu to others in case they are in the early stages of infection.

* Talk to your health care provider about taking antiviral medication to prevent the caregiver from getting the flu.

* Monitor yourself and household members for flu symptoms and contact a telephone hotline or health care provider if symptoms occur.



|Using Facemasks or Respirators|

Using Facemasks or Respirators



* Avoid close contact (less than about 6 feet away) with the sick person as much as possible.

* If you must have close contact with the sick person (for example, hold a sick infant), spend the least amount of time possible in close contact and try to wear a facemask (for example, surgical mask) or N95 disposable respirator.

* An N95 respirator that fits snugly on your face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through an N95 mask for long periods of time. More information on facemasks and respirators can be found at www.cdc.gov/swineflu

* Facemasks and respirators may be purchased at a pharmacy, building supply or hardware store.

* Wear an N95 respirator if you help a sick person with respiratory treatments using a nebulizer or inhaler, as directed by their doctor. Respiratory treatments should be performed in a separate room away from common areas of the house when at all possible.

* Used facemasks and N95 respirators should be taken off and placed immediately in the regular trash so they don't touch anything else.

* Avoid re-using disposable facemasks and N95 respirators if possible. If a reusable fabric facemask is used, it should be laundered with normal laundry detergent and tumble-dried in a hot dryer.

* After you take off a facemask or N95 respirator, clean your hands with soap and water or an alcohol-based hand sanitizer.



|Household Cleaning, Laundry, and Waste Disposal|

Household Cleaning, Laundry, and Waste Disposal



* Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste.

* Keep surfaces (especially bedside tables, surfaces in the bathroom, and toys for children) clean by wiping them down with a household disinfectant according to directions on the product label.

* Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first.

* Wash linens (such as bed sheets and towels) by using household laundry soap and tumble dry on a hot setting. Avoid "hugging" laundry prior to washing it to prevent contaminating yourself. Clean your hands with soap and water or alcohol-based hand rub right after handling dirty laundry.

* Eating utensils should be washed either in a dishwasher or by hand with water and soap.



For More Information

The Centers for Disease Control and Prevention (CDC) Hotline (1-800-CDC-INFO) is available in English and Spanish, 24 hours a day, 7 days a week. 



---------------------------------------------------------------------------------------------------------------------------

~Screening~

Screening



Screening Interim Guidance for Screening for Swine-Origin Influenza A (H1N1) by State and Local Health Departments, Hospitals, and Clinicians in Regions with Few or no Reported Cases of Swine Influenza A (H1N1)



This document provides interim guidance for state and local health departments, hospitals, and clinicians in regions with few or no reported cases of swine-origin influenza A (H1N1) (S-OIV) regarding which patients to evaluate for possible infection with swine influenza A (H1N1). As of April 29 1:00 PM, there were 91 laboratory confirmed cases of S-OIV infection identified in 10 states in the United States. Human cases of S-OIV infection also have been identified internationally. Based on the rapid spread of the S-OIV thus far, public health officials believe that more cases will be identified over the next several weeks, including in regions that currently have few or no reported cases. 



CDC recommends that state and local health departments, hospitals, and clinicians in regions with few or no reported cases of S-OIV consider the following recommendations for testing of the following persons for S-OIV infection with a nasopharyngeal swab by PCR:



1. Patients presenting to providers participating in the US Outpatient Influenza-like Illness Surveillance Network (ILINet) who meet the case definition of influenza-like illness (ILI), or

2. Patients with an ILI who have traveled within 7 days to a community either within the United States or internationally where there are one or more confirmed swine influenza A (H1N1) cases, or

3. Patients admitted to the hospital with an ILI.



ILI is defined as fever (temperature of 100øF [37.8øC] or greater) and a cough and/or a sore throat in the absence of a KNOWN cause other than influenza.



|Specimen Collection and Testing|

Specimen Collection and Testing



If swine flu is suspected, clinicians should obtain a respiratory swab for S-OIV testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory. State public health laboratories should perform subtype testing on all influenza A positive samples identified. State public health laboratories should submit all specimens that cannot be subtyped as human influenza A (H1N1) or (H3N2) to CDC for identification. Please notify CDC of all pending shipments by email at eocsciresource@cdc.gov or if email is not available, by phone at 404-553-7724. Please include shipment tracking information.





|Investigation of Cases|

Investigation of Cases



Officials should conduct thorough case and contact investigations to determine the source of the swine influenza virus, extent of community illness and the need for timely control measures.





|Interim Guidance|

Interim Guidance



* Interim Guidance is available, including:

* Case definitions to be used for swine influenza A (H1N1) cases

* Antiviral recommendations for patients with confirmed or suspected S-OIV infection and close contacts

* Infection control for care of persons with confirmed or suspected S-OIV infection in a healthcare setting

* S-OIV biosafety guidelines for laboratory workers.







* Links to non-federal organizations are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.



---------------------------------------------------------------------------------------------------------------------------





~Information for Concerned Parents and Caregivers~



|What is H1N1 (swine flu)?|

What is H1N1 (swine flu)?

H1N1 (swine flu) is a type of influenza (flu) virus that causes respiratory disease that can spread between people. Most people infected with this virus in the United States have had mild disease, but some have had more severe illness, and there has been at least one death. Young children, pregnant women, and people with chronic diseases like asthma, diabetes, or heart disease may be at higher risk for complications from this infection. More information about who may be at higher risk will be available when more is known about the disease. There are steps you can take to protect your family and to know when to seek medical care.



|What are the symptoms?|

What are the symptoms?

In most children, the symptoms of H1N1 (swine flu) are similar to the symptoms of regular flu. They include:



* Fever

* Cough

* Sore throat

* Body aches

* Headache

* Chills and fatigue

* Occasionally, vomiting and diarrhea





Young children may not have typical symptoms, but may have difficulty breathing and low activity. Little is known about how H1N1 (swine flu) may affect children. However, we think the infection may be similar to other flu infections. Typically, flu infections cause mild disease in children, but children under 5 years old are more likely to have serious illness than older children. Although rare, severe respiratory illness (pneumonia) and deaths have been reported with flu infections in children. Flu infections tend to be more severe in children with chronic medical conditions.



|How to keep from getting it:|

How to keep from getting it:

Flu viruses spread from person to person mainly through the coughing or sneezing of a sick person. Flu virus may also be spread when a person touches something that is contaminated with the virus and then touches his or her eyes, nose, or mouth. We think H1N1 (swine flu) spreads the same way as other flu viruses. Right now, there is no vaccine to protect against H1N1 (swine flu), but there are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like H1N1 (swine flu):



* Teach your children to wash their hands frequently with soap and water for 20 seconds. Be sure to set a good example by doing this yourself.

* Teach your children to cough and sneeze into a tissue or into the inside of their elbow. Be sure to set a good example by doing this yourself.

* Teach your children to stay at least six feet away from people who are sick.

* Children who are sick should stay home from school and daycare and stay away from other people until they are better.

* In communities where H1N1 (swine flu) has occurred, stay away from shopping malls, movie theaters, or other places where there are large groups of people.







|What to do if your child is sick:|

What to do if your child is sick:



* Unless they need medical attention, keep children who are sick at home. Don't send them to school or daycare.

* Have them drink a lot of liquid (juice, water, Pedialyte r).

* Keep the sick child comfortable. Rest is important.

* For fever, sore throat, and muscle aches, you can use fever-reducing medicines that your doctor recommends based on your child's age. Do not use aspirin with children or teenagers; it can cause Reye's syndrome, a life-threatening illness.

* If someone in your home is sick, keep him or her away from those who are not sick.

* Keep tissues close to the sick person and have a trash bag within reach for disposing used tissues.



If your child comes in contact with someone with H1N1 (swine flu), ask your doctor if he or she should receive antiviral medicines to prevent getting sick from H1N1 (swine flu).

If your child experiences any of the following warning signs, seek emergency medical care:



* Fast breathing or trouble breathing

* Bluish or gray skin color

* Not drinking enough fluids

* Not waking up or not interacting

* Being so irritable that he or she does not want to be held

* Not urinating or no tears when crying

* Their symptoms improve but then return with fever and worse cough



For more information call 1-800-CDC INFO, or go to http://www.cdc.gov/swineflu 



--------------------------------------------------------------------------------------------------------------------------- 



~Information for Child Care Providers~

Information for Child Care Providers



CDC has identified cases of swine-origin influenza A (H1N1) virus infection in people from several states including California, Kansas, Texas, New York and other states (see updates at www.cdc.gov/swineflu). CDC is working with local and state health agencies to investigate these cases. It has been determined that this virus is spreading from human to human.



Mexico has reported increased levels of respiratory disease including reports of severe pneumonia cases and deaths. The swine-origin influenza viruses identified by CDC from cases in Mexico are similar to viruses from patients in the United States. As of April 29, 2009, of 91 patients identified thus far in the US, most have recovered, but five have been hospitalized and one patient, a child, has died. However, the CDC is concerned about these cases in the United States and the World Health Organization are concerned about continued spread of this new virus. Right now, there is no vaccine for this new virus and the current seasonal influenza is thought to be unlikely to provide protection against this new strain.



Child care providers in community based child care programs in all settings including both center-based and family child care programs should:



* Review their plans for responding to a pandemic. Make sure that they are up to date and that parents know what they are.

* Remind parents and enforce policies for having ill children stay at home during their illness. Children with symptoms of an influenza-like illness should not come to school. Symptom of influenza include fever, cough, sore throat, body aches, headache, chills, fatigue, and, in some cases diarrhea. The child's health care provider will determine whether influenza testing is needed and when the child can return to child care. In most areas, children with other, mild respiratory illnesses including allergies may be allowed to attend child care as long they are able to participate comfortably and their care does not result in a greater need for care than the staff can provide without compromising the health and safety of the other children (Caring for Our Children- Standard 3.065). 



* Remind workers not to come to work while if they have an influenza like illness. They should consult their health care provider to determine whether influenza testing is needed.



* Health departments in areas where cases of persons affected with this new virus have been identified may recommend more rigid exclusion policies so providers will need to stay informed on what is happening in their communities.



* Child with influenza may be infectious for up to 10 days after illness onset with influenza while adults are thought to likely infectious for 5-7 days. Public health investigators are working to more precisely learn the length of infectiousness. If a child has been confirmed to have swine-origin influenza, then seek the advice of the child's health provider and the health department about when the child can return to the child care program

* Be familiar with local/state plans for child care in the event of a mild or severe pandemic. This information may be available from state or local health authorities, child care licensing agencies or resource and referral agencies. If these plans do not include specific approaches to communicate with and handle situations in child care, do what you can to advocate for updating the plans.

* Develop and implement a system to track illness and absence due to illness among children and staff if one is not already in place. The system should be simple and easy to maintain but should record the number of persons with various illnesses (e.g. respiratory, diarrhea, rash) by day or at least by week. (see Caring for Our Children Standards 3.001 and 3.002 for information on how to do this (http://nrckids.org/CFOC/PDFVersion/Chapter%203.pdf - page 2)

* Review and implement CDC Guidelines and Recommendations for Preventing the Spread of Influenza (the Flu) in Child Care Settings: Guidance for Administrators, Care Providers, and Other Staff, ( http://www.cdc.gov/flu/professionals/infectioncontrol/childcaresettings.htm)

* Make sure staff are familiar with the above guidelines and that they are being followed in your program. Remind child care staff to clean/disinfect frequently touched surfaces within the facility.

* Provide information to parents on steps that they could take to prevent flu. (See attached fact sheet that could be distributed to each parent or posted on a door to the facilities with providers calling attention to the posted fact sheet).

* Monitor the postings on the CDC web site about this virus (www.cdc.gov/swineflu) and information from state or local health departments to see if child care facilities should begin preparing for possible closure or changes in operation.

* Work with parents to consult the child's health provider if you have questions about a child with a respiratory illness or if you suspect a child might have influenza. Contact your child care health consultant or local public health department if you need help to make decisions promptly that affect the children as a group



Child care and preschool programs can help protect the health of their staff and the children and families they serve by calling attention to the every day preventive actions that parents can initiate to protect their children. (Please consider posting or distributing the attached message in your child care facility).

More information on preventing the spread of influenza can be found at: http://www.pandemicflu.gov/plan/school/preschool.html. For generic information on disaster preparedness, see NACCRRA's web site http://www.naccrra.org/for_parents/coping/disaster.php

Additional generic planning information for child care programs and schools, including examples of state and local plans, can be found on the Department of Education's website at: http://www.ed.gov/admins/lead/safety/emergencyplan/pandemic/index.html. 



Note: Conditions and situations are rapidly changing and these recommendations may change over time.



|Preventing the Flu: Good Health Habits Can Help Stop Germs|

Preventing the Flu: Good Health Habits Can Help Stop Germs



Fact Sheet



1. Avoid close contact.



* Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.



2. Stay home when you are sick.



* Stay home from work, child care, school, and errands when you are sick, except to seek medical careKeep sick children at home except to see medical care. You will help prevent others from catching the illness.



3. Cover your mouth and nose.



* Cover your mouth and nose with a tissue when coughing or sneezing. Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.



4. Wash your hands often.



* Washing your hands and the hands of your children often will help protect you from germs.



5. Avoid touching your eyes, nose or mouth.



* Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.



6. Practice other good health habits.



* Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.





There is no vaccine available at this time for this new flu virus , so it is important for people living in the affected areas to take steps to prevent spreading the virus to others. If people are ill, they should stay at home and limit contact with others, except to seek medical care. Healthy residents living in these areas should take the everyday preventive actions listed above.



People who live in these areas who develop an illness with fever and respiratory symptoms, such as cough and runny nose, and possibly other symptoms, such as body aches, nausea, or vomiting or diarrhea, should contact their health care provider. Their health care provider will determine whether influenza testing is needed.



---------------------------------------------------------------------------------------------------------------------------



~Guidance for Clinicians on the Prevention and Treatment in Young Children~

Guidance for Clinicians on the Prevention and Treatment in Young Children



Interim Guidance for Clinicians on the Prevention and Treatment of Swine-Origin Influenza Virus Infection in Young Children



This document provides interim guidance for clinicians who are caring for young children with confirmed or suspected swine-origin influenza A (H1N1) virus infection.



|Background|

|Background|



|Young children and swine-origin influenza virus (S-OIV)|

Young children and swine-origin influenza virus (S-OIV)



Little is currently known about how this new S-OIV circulating in people may affect children. However, we know from seasonal influenza and past pandemics that young children, especially those younger than 5 years of age and children who have high risk medical conditions, are at increased risk of influenza-related complications.



Illnesses caused by influenza virus infection are difficult to distinguish from illnesses caused by other respiratory pathogens based on symptoms alone. Young children are less likely to have typical influenza symptoms (e.g., fever and cough) and infants may present to medical care with fever and lethargy, and may not have cough or other respiratory symptoms or signs.



Influenza-associated deaths among children, while uncommon, do occur with seasonal influenza with an estimated average of approximately 92 influenza-related pediatric deaths each year in the United States. Some deaths in children have been associated with co-infection with influenza and Staphylococcus aureus, particularly methicillin resistant S. aureus (MRSA).



|Symptoms of severe disease may include:|

Symptoms of severe disease may include:





* Apnea

* Tachypnea

* Dyspnea

* Cyanosis

* Dehydration

* Altered mental status

* Extreme irritability



|Treatment and prevention of swine flu|

Treatment and prevention of swine flu



No vaccine is currently available to prevent S-OIV infection and it is thought unlikely that seasonal influenza vaccine will provide protection against this new virus. While not a substitute for a vaccine, a number of other interventions may be used to decrease the risk of infection and possible complications from S-OIV infection in children.



Influenza antiviral medications for use in children age 1 year and older



Antiviral treatment with oseltamivir or zanamivir is recommended for children with confirmed or probable S-OIV infection. See www.cdc.gov/swineflu/casedef_swineflu.htm for case definitions. Empiric antiviral treatment is also recommended for children with suspected cases of swine influenza A (H1N1) virus infection, especially those with severe illness. Antiviral treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of symptoms. Evidence for benefits from treatment in studies of seasonal influenza is strongest when treatment is started within 48 hours of illness onset. However, some studies of treatment of seasonal influenza have indicated benefit, including reductions in mortality or duration of hospitalization even for patients whose treatment was started more than 48 hours after illness onset. Recommended duration of treatment is five days. Recommendations for use of antivirals may change as data on antiviral effectiveness, side effects and antiviral susceptibilities become available. Antiviral doses recommended for treatment of S-OIV infection in children 1 year of age or older are the same as those recommended for seasonal influenza (Table 1).

Table 1. Recommended doses of zanamivir and oseltamivir antiviral medications for the treatment and prevention of influenza in children 1-18 years-old





|Antiviral agent Age group (yrs)|

Antiviral agent Age group (yrs)



1-6 7-9 10-12 13-18

Zanamivir* Treatment, influenza A and B N/A+ 10 mg (2 inhalations) twice daily 10 mg (2 inhalations) twice daily 10 mg (2 inhalations) twice daily

Chemoprophylaxis, influenza A and B Ages 1-4

N/A Ages 5-9

10 mg (2 inhalations) once daily 10 mg (2 inhalations) once daily 10 mg (2 inhalations) once daily

Oseltamivir Treatment+, influenza A and B Dose varies by child's weight	Dose varies by child's weight Dose varies by child's weight 75 mg twice daily

Chemoprophylaxis, influenza A and B Dose varies by child's weight Dose varies by child's weight Dose varies by child's weight 75 mg/day

Duration of Treatment Treatment Recommended duration for antiviral treatment is 5 days.

Chemoprophylaxis Recommended duration is 10 days after the last known exposure.



Children Younger than 1 Year of Age



Children less than one year of age are at higher risk for complications associated with seasonal human influenza virus infections compared to older children, and the risk of influenza complications is especially high for children less than 6 months of age. The characteristics of human infections with S-OIV are still being studied, and it is not known whether infants are at higher risk for complications associated with S-OIV infection compared to older children. However, children less than 1 year old are known to be at increased risk of complications from seasonal influenza infection and during previous pandemics. Limited safety data on the use of oseltamivir (or zanamivir) is available from children less than one year of age, and oseltamivir is not licensed for use in children less than 1 year old. Available data comes from use of oseltamivir for treatment of seasonal influenza. However, these data suggest that severe adverse events are rare, and the Infectious Diseases Society of America recently noted that ". limited retrospective data on the safety and efficacy of oseltamivir in this young age group have not demonstrated age-specific drug-attributable toxicities to date.".



Because infants typically have higher rates of morbidity and mortality from influenza compared to healthy older children, infants with S-OIV infections may benefit from treatment using oseltamivir. Oseltamivir use for children less than 1 year old was recently approved by the FDA under an Emergency Use Authorization (EUA), and dosing for these children is age-based. (Table 2).



Table 2. Recommended doses of oseltamivir antiviral medication for the treatment of S-OIV influenza for children less than 1 year of age.

Age Recommended treatment dose for 5 days

<3 months 12 mg twice daily

3-5 months 20mg twice daily

6-11 months 25 mg twice daily



|Use of fever-reducing medications in children|

Use of fever-reducing medications in children



Aspirin or aspirin-containing products (e.g. bismuth subsalicylate - Pepto Bismol) should not be administered to any confirmed or suspected ill case of swine influenza A (H1N1) virus infection aged 18 years old and younger due to the risk of Reye syndrome. For relief of fever, other anti-pyretic medications are recommended such as acetaminophen or non steroidal anti-inflammatory drugs.



Antiviral Chemoprophylaxis



For antiviral chemoprophylaxis of S-OIV infection, either oseltamivir or zanamivir are recommended for children 1 year of age or older (Table 1). Oseltamivir can be used for chemoprophylaxis under the EUA for children less than 1 year-old (Table 3). Under this EUA, chemoprophylaxis is not recommended for infants less than 3 months old unless the situation is judged to be critical. Duration of antiviral chemoprophylaxis post-exposure is 10 days after the last known exposure to an ill confirmed case of swine influenza A (H1N1) virus infection. For pre-exposure protection, chemoprophylaxis should be given during the potential exposure period and continued for 10 days after the last known exposure to an ill confirmed case of swine influenza A (H1N1) virus infection.



Table 3. Recommended doses of oseltamivir antiviral medication for the prevention of swine influenza for children less than 1 year of age.



TABLE 3 HERE

Age Recommended prophylaxis dose for 10 days

<3 months Not recommended unless situation judged critical

3-5 months 20mg once daily

6-11 months 25 mg once daily



Antiviral chemoprophylaxis with either oseltamivir or zanamivir is recommended for the following children:



1. Household close contacts who are at high-risk for complications of influenza (children younger than 5 years old , pregnant women, persons =65 years-old and those with certain chronic medical conditions) of a confirmed or suspected case.

2. School children or daycare attendees who are at high-risk for complications of influenza (children younger than 5 years old, pregnant women, persons =65 years-old and those with certain chronic medical conditions) who had close contact (face-to-face) with a confirmed, probable, or suspected case.

3. Children who traveled to Mexico who are at high-risk for complications of influenza (children younger than 5 years old pregnant women, persons =65 years-old and those with certain chronic medical conditions).



|Other measures to prevent swine influenza in children|

Other measures to prevent swine influenza in children



* In addition to antiviral medications, other information on measures that can help prevent the spread of influenza can be found at www.cdc.gov/swineflu under the following headings:

* Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been Detected

* Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home

* Interim Guidance on Antiviral Recommendations for Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection and Close Contacts

* Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting Apr 24, 2009



Interim CDC Guidance for Nonpharmaceutical Community Mitigation in Response to Human Infections with Swine Influenza (H1N1) Virus



---------------------------------------------------------------------------------------------------------------------------

~Guidance for Emergency Medical Services (EMS) System for Management of Patients with Confirmed or Suspected Infection~

Guidance for Emergency Medical Services (EMS) System for Management of Patients with Confirmed or Suspected Infection





Guidance for Emergency Medical Services (EMS) System for Management of Patients with Confirmed or Suspected Infection 

Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Confirmed or Suspected Swine-Origin Influenza A (H1N1) Infection



This document provides interim guidance for 9-1-1 Public Safety Answering Points (PSAPs), the EMS system and medical first-responders and will be updated as needed at http://www.cdc.gov/swineflu/guidance/. The information contained in this document is intended to complement existing guidance for healthcare personnel, "Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting" at http://www.cdc.gov/swineflu/guidelines_infection_control.htm.



|Background|

Background

As a component of the Nation's critical infrastructure, emergency medical services (along with other emergency services) play a vital role in responding to requests for assistance, triaging patients, and providing emergency treatment to influenza patients. However, unlike patient care in the controlled environment of a fixed medical facility, prehospital EMS patient care is provided in an uncontrolled environment, often confined to a very small space, and frequently requires rapid medical decision-making, and interventions with limited information. EMS personnel are frequently unable to determine the patient history before having to administer emergency care.



|Interim Recommendations|

Interim Recommendations

Coordination among PSAPs, the EMS system, healthcare facilities (e.g. emergency departments), and the public health system is important for a coordinated response to swine-origin influenza A (H1N1). Each 9-1-1 and EMS system should seek the involvement of an EMS medical director to provide appropriate medical oversight. Given the uncertainty of the disease, its treatment, and its progression, the ongoing role of EMS medical directors is critically important. The guidance provided in this document is based on current knowledge of swine-origin influenza A (H1N1).



The U.S. Department of Transportation's EMSPandemic Influenza Guidelines for Statewide Adoption and Preparing for Pandemic Influenza: Recommendations for Protocol Development and 9-1-1 Personnel and Public Safety Answering Points (PSAPs) are available online at www.ems.gov (Click on Pandemic News). State and local EMS agencies should review these documents for additional information. For instance, Guideline 6.1 addresses protection of the EMS and 9-1-1 workers and their families while Guideline 6.2 addresses vaccines and antiviral medications for EMS personnel. Also, EMS Agencies should work with their occupational health programs and/or local public health/public safety agencies to make sure that long term personal protective equipment (PPE) needs and antiviral medication needs are addressed. 



|Infectious Period|

Infectious Period

Persons with swine-origin influenza A (H1N1) virus infection should be considered potentially infectious from one day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might potentially be contagious for longer periods.



Non-hospitalized ill persons who are a confirmed or suspected case of swine-origin influenza A (H1N1) virus infection are recommended to stay at home (voluntary isolation) for at least the first 7 days after checking with their health care provider about any special care they might need if they are pregnant or have a health condition such as diabetes, heart disease, asthma, or emphysema. CDC guidance on care of patients at home can be found at http://www.cdc.gov/swineflu/guidance_homecare.htm )



Case Definitions for Infection with Swine-origin Influenza A (H1N1) Virus (S-OIV)



A confirmed case of S-OIV infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests:



1. real-time RT-PCR

2. viral culture



A probable case of S-OIV infection is defined as a person with an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR



A suspected case of S-OIV infection is defined as a person with acute febrile respiratory illness with onset



* within 7 days of close contact with a person who is a confirmed case of S-OIV infection, or

* within 7 days of travel to community either within the United States or internationally where there are one or more confirmed cases of S-OIV infection, or

* resides in a community where there are one or more confirmed cases of S-OIV infection.



|Recommendations for 9-1-1 Public Safety Answering Points (PSAP)|

Recommendations for 9-1-1 Public Safety Answering Points (PSAP)



It is important for the PSAPs to question callers to ascertain if there is anyone at the incident location who is possibly afflicted by the swine-origin influenza A (H1N1) virus, to communicate the possible risk to EMS personnel prior to arrival, and to assign the appropriate EMS resources. PSAPs should review existing medical dispatch procedures and coordinate any modifications with their EMS medical director and in coordination with their local department of public health.



Interim recommendations: 



* PSAP call takers should screen all callers for any symptoms of acute febrile respiratory illness. Callers should be asked if they, or someone at the incident location, has had nasal congestion, cough, fever or other flu-like symptoms.



* If the PSAP call taker suspects a caller is noting symptoms of acute febrile respiratory febrile illness, they should make sure any first responders and EMS personnel are aware of the potential for "acute febrile respiratory illness" before the responders arrive on scene.



Recommendations for EMS and Medical First Responder Personnel Including Firefighter and Law Enforcement First Responders

For purposes of this section, "EMS providers" means prehospital EMS, Law Enforcement and Fire Service First Responders." EMS providers' practice should be based on the most up-to-date swine-origin influenza clinical recommendations and information from appropriate public health authorities and EMS medical direction. 



|Patient assessment:|

Patient assessment: 



Interim recommendations:



If there HAS NOT been swine-origin influenza reported in the geographic area (http://www.cdc.gov/swineflu/), EMS providers should assess all patients as follows:



* Step 1: EMS personnel should stay more than 6 feet away from patients and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of swine-origin influenza.



* Step 2: Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: nasal congestion/ rhinorrhea, sore throat, or cough).

*

o If no acute febrile respiratory illness, proceed with normal EMS care.

o If symptoms of acute febrile respiratory illness, then assess all patients for travel to a geographic area with confirmed cases of swine-origin influenza within the last 7 days or close contact with someone with travel to these areas.

o

+ If travel exposure, don appropriate PPE for suspected case of swine-origin influenza.

+ If no travel exposure, place a standard surgical mask on the patient (if tolerated) and use appropriate PPE for cases of acute febrile respiratory illness without suspicion of swine-origin influenza (as described in PPE section).



If the CDC confirmed swine-origin influenza in the geographic area (http://www.cdc.gov/swineflu/ )



* Step 1: Address scene safety:

*

o If PSAP advises potential for acute febrile respiratory illness symptoms on scene, EMS personnel should don PPE for suspected cases of swine-origin influenza prior to entering scene.

o If PSAP has not identified individuals with symptoms of acute febrile respiratory illness on scene, EMS personnel should stay more than 6 feet away from patient and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of swine-origin influenza.



* Step 2: Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: nasal congestion/ rhinorrhea, sore throat, or cough).



* If no symptoms of acute febrile respiratory illness, provide routine EMS care.

* If symptoms of acute febrile respiratory illness, don appropriate PPE for suspected case of swine-origin influenza if not already on.



|Personal protective equipment (PPE):|

Personal protective equipment (PPE):



Interim recommendations:



* When treating a patient with a suspected case of swine-origin influenza as defined above, the following PPE should be worn:

*

o Fit-tested disposable N95 respirator and eye protection (e.g., goggles; eye shield), disposable non-sterile gloves, and gown, when coming into close contact with the patient.

* When treating a patient that is not a suspected case of swine-origin influenza but who has symptoms of acute febrile respiratory illness, the following precautions should be taken:

*

o Place a standard surgical mask on the patient, if tolerated. If not tolerated, EMS personnel may wear a standard surgical mask.

o Use good respiratory hygiene - use non-sterile gloves for contact with patient, patient secretions, or surfaces that may have been contaminated. Follow hand hygiene including hand washing or cleansing with alcohol based hand disinfectant after contact.



* Encourage good patient compartment vehicle airflow/ ventilation to reduce the concentration of aerosol accumulation when possible.





|Infection Control:|

Infection Control:



EMS agencies should always practice basic infection control procedures including vehicle/equipment decontamination, hand hygiene, cough and respiratory hygiene, and proper use of FDA cleared or authorized medical personal protective equipment (PPE).



Interim recommendations:



* Pending clarification of transmission patterns for this virus, EMS personnel who are in close contact with patients with suspected or confirmed swine-origin influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator, disposable non-sterile gloves, eye protection (e.g., goggles; eye shields), and gown, when coming into close contact with the patient.

* All EMS personnel engaged in aerosol generating activities (e.g. endotracheal intubation, nebulizer treatment, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) should wear a fit-tested disposable N95 respirator, disposable non-sterile gloves, eye protection (e.g., goggles; eye shields), and gown, unless EMS personnel are able to rule out acute febrile respiratory illness or travel to an endemic area in the patient being treated.



* All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient.





|Interfacility Transport|

Interfacility Transport



EMS personnel involved in the interfacility transfer of patients with suspected or confirmed swine-origin influenza should use standard, droplet and contact precautions for all patient care activities. This should include wearing a fit-tested disposable N95 respirator, wearing disposable non-sterile gloves, eye protection (e.g., goggles, eyeshield), and gown, to prevent conjunctival exposure. If the transported patient can tolerate a facemask (e.g., a surgical mask), its use can help to minimize the spread of infectious droplets in the patient care compartment. Encourage good patient compartment vehicle airflow/ ventilation to reduce the concentration of aerosol accumulation when possible.



Interim Guidance for Cleaning EMS Transport Vehicles After Transporting a Suspected or Confirmed Swine-origin Influenza Patient



The following are general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a suspected or confirmed swine-origin influenza patient. This guidance may be modified or additional procedures may be recommended by the Centers for Disease Control and Prevention (CDC) as new information becomes available. 



Routine cleaning with soap or detergent and water to remove soil and organic matter, followed by the proper use of disinfectants, are the basic components of effective environmental management of influenza. Reducing the number of influenza virus particles on a surface through these steps can reduce the chances of hand transfer of virus. Influenza viruses are susceptible to inactivation by a number of chemical disinfectants readily available from consumer and commercial sources.



After the patient has been removed and prior to cleaning, the air within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running. This should be done outdoors and away from pedestrian traffic. Routine cleaning methods should be employed throughout the vehicle and on non-disposable equipment. 



For additional detailed guidance on ambulance decontamination EMS personnel may refer to "Interim Guidance for Cleaning Emergency Medical Service Transport Vehicles during an Influenza Pandemic" available at: http://www.pandemicflu.gov/plan/healthcare/cleaning_ems.html .



EMSTransfer of Patient Care to a Healthcare Facility



When transporting a patient with symptoms of acute febrile respiratory illness, EMS personnel should notify the receiving healthcare facility so that appropriate infection control precautions may be taken prior to patient arrival. Patients with acute febrile respiratory illness should wear a surgical mask, if tolerated. Small facemasks are available that can be worn by children, but it may be problematic for children to wear them correctly and consistently. Moreover, no facemasks (or respirators) have been cleared by the FDA specifically for use by children.



---------------------------------------------------------------------------------------------------------------------------

~Interim Guidance Pregnant Women and Swine Influenza~

Interim Guidance Pregnant Women and Swine Influenza



Interim Guidance-Pregnant Women and Swine Influenza: Considerations for Clinicians 



|Background|

Background



Human infections with a swine influenza A (H1N1) virus that is easily transmissible among humans were first identified in April 2009 with cases in the United States and Mexico. The epidemiology and clinical presentations of these infections are currently under investigation. There are insufficient data available at this point to determine who is at higher risk for complications of swine influenza A (H1N1) virus infection. However, in 1988 a previously healthy 32-year-old pregnant woman was hospitalized for pneumonia and died 8 days later after infection with another variant of swine influenza virus. Pregnant women are also known to be higher risk for seasonal influenza complications and during prior pandemics, and it is reasonable to assume that pregnant women are also at higher risk for swine influenza complications.



Evidence that influenza can be more severe in pregnant women comes from observations during previous pandemics and from studies among pregnant women who had seasonal influenza. An excess of influenza-associated deaths among pregnant women were reported during the pandemics of 1918-1919 and 1957-1958. Adverse pregnancy outcomes have been reported following previous influenza pandemics, with increased rates of spontaneous abortion and preterm birth reported, especially among women with pneumonia. Case reports and several epidemiologic studies conducted during interpandemic periods also indicate that pregnancy increases the risk for influenza complications for the mother and might increase the risk for adverse perinatal outcomes or delivery complications.



|Clinical Presentation|

Clinical Presentation



Pregnant women with swine influenza would be expected to present with typical acute respiratory illness (e.g., cough, sore throat, rhinorrhea) and fever or feverishness. Many pregnant women will go on to have a typical course of uncomplicated influenza. However, for some pregnant women, illness might progress rapidly, and might be complicated by secondary bacterial infections including pneumonia. Fetal distress associated with severe maternal illness can occur. Pregnant women who have suspected swine influenza A (H1N1) virus infection should be tested (http://www.cdc.gov/swineflu/specimencollection.htm), and specimens from women who have unsubtypeable influenza A virus infections should have specimens sent to the state public health laboratory for additional testing to identify swine influenza A (H1N1).



|Treatment|

Treatment and chemoprophylaxis



The currently circulating swine influenza A (H1N1) virus is sensitive to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir, but is resistant to the adamantane antiviral medications, amantadine and rimantadine. Pregnant women who meet current case-definitions for confirmed, probable or suspected swine influenza A (H1N1) infection should receive empiric antiviral treatment. Pregnant women who are close contacts with persons with suspected, probable or confirmed cases of swine influenza A (H1N1) should receive antiviral chemoprophylaxis. These recommendations for treatment and chemoprophylaxis are the same ones used for others who are at higher risk of complications from influenza.



As is recommended for other persons who are treated, antiviral treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of influenza symptoms, with benefits expected to be greatest if started within 48 hours of onset based on date from studies of seasonal influenza. However, some data from studies on seasonal influenza indicate benefit for hospitalized patients even if treatment is started more than 48 hours after onset. Recommended duration of treatment is five days, and for chemoprophylaxis is 10 days. Oseltamivir and zanamivir treatment and chemoprophylaxis regimens recommended for pregnant women are the same as those recommended for adults who have seasonal influenza. Recommendations for use of antivirals for pregnant women might change as additional data on the benefits and risks of antiviral therapy in pregnant women become available.



Oseltamivir and zanamivir are "Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, oseltamivir or zanamivir should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus. However, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to women who have received oseltamivir or zanamivir. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Pregnant women might be at higher risk for severe complications from swine influenza, and the benefits of treatment or chemoprophylaxis with zanamivir or oseltamivir likely outweigh the theoretical risks of antiviral use. Because of its systemic activity, oseltamivir is preferred for treatment of pregnant women. The drug of choice for prophylaxis is less clear. Zanamivir may be preferable because of its limited systemic absorption; however, respiratory complications and medication delivery system challenges that may be associated with zanamivir because of its inhaled route of administration need to be considered, especially in women at risk for respiratory problems.



Several studies have shown that fever during pregnancy is associated with an increased risk of birth defects and other adverse outcomes. For this reason, fever in pregnant women should be treated. Acetaminophen appears to be the best option for treatment of fever during pregnancy.



Other ways to reduce risk for pregnant women



The risk for swine influenza A (H1N1) might be reduced by taking steps to reduce the chance of being exposed to respiratory infections. There is no vaccine available yet to prevent swine influenza A (H1N1). These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household who may be ill with swine flu. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. A respirator that fits snugly on the face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through a respirator for long periods of time.



|Breastfeeding considerations|

Breastfeeding considerations



Women who are breastfeeding can continue while receiving antivirals. However, women who are ill with swine influenza A (H1N1) should take steps to reduce the risk to their infants, such as frequent hand washing and possibly wearing a mask (see below). The risk for swine influenza transmission through breast milk is unknown. However, reports of viremia with seasonal influenza infection are rare.



Efforts to identify the risk for pregnant women from swine influenza A (H1N1) during 2009 are underway. Enhanced surveillance for hospitalized patients with swine influenza A (H1N1) has been initiated. Additional information about swine influenza is available.



---------------------------------------------------------------------------------------------------------------------------

~Guidance on Specimen Collection and Testing~

Guidance on Specimen Collection and Testing



Interim Guidance on Specimen Collection, Processing, and Testing for Patients with Suspected Swine-Origin Influenza A (H1N1) Virus Infection Objective:To provide interim guidance on appropriate specimen collection, storage, processing, and testing for patients with suspected swine-origin influenza A (H1N1) virus infection.



Case Definitions



A confirmed case of S-OIV infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests:



1. real-time RT-PCR

2. viral culture



|Case definitions for probable and suspected cases|.

Case definitions for probable and suspected cases.



Duration of viral shedding



The duration of shedding with swine-origin influenza A (H1N1) virus is unknown. Therefore, until data are available, the estimated duration of viral shedding is based upon seasonal influenza virus infection. Infected persons are assumed to be shedding virus and potentially infectious from the day prior to illness onset until resolution of fever. Infected persons should be assumed to be contagious up to 7 days days from illness onset. Some persons who are infected might potentially shed virus and be contagious for longer periods (e.g. young infants, immunosuppressed, and immunocompromised persons). 



Testing for swine-origin influenza A (H1N1) virus



Clinicians should consider testing suspected cases of swine-origin influenza A (H1N1), especially those with severe illness, by obtaining an upper respiratory specimen to test for swine-origin influenza A (H1N1) virus.



Preferred respiratory specimens: The following should be collected as soon as possible after illness onset: nasopharyngeal swab/aspirate or nasal wash/aspirate. If these specimens cannot be collected, a combined nasal swab with an oropharyngeal swab is acceptable. For patients who are intubated, an endotracheal aspirate should also be collected. Specimens should be placed into sterile viral transport media (VTM) and immediately placed on ice or cold packs or at 4øC (refrigerator) for transport to the laboratory. Recommended infection control guidance is available for persons collecting clinical specimens in clinics and other clinical settings and laboratory personnel.



Swabs



Ideally, swab specimens should be collected using swabs with a synthetic tip (e.g. polyester or Dacronr) and an aluminum or plastic shaft. Swabs with cotton tips and wooden shafts are not recommended. Specimens collected with swabs made of calcium alginate are not acceptable. The swab specimen collection vials should contain 1-3ml of viral transport medium (e.g. containing, protein stabilizer, antibiotics to discourage bacterial and fungal growth, and buffer solution), such M4RT or the BD Universal Viral Transport System.



Storing Clinical Specimens: All respiratory specimens should be kept at 4øC until they can be placed at -70øC. If a -70øC freezer is not available, specimens should be kept at 4øC, preferably no longer than 1 week. 



Shipping clinical specimens: Clinical specimens should be shipped on dry ice in appropriate packaging.

All specimens should be labeled clearly and include information requested by your state public health laboratory. Suspected case specimens shipped from the state public health laboratory to CDC should include all information required for seasonal influenza surveillance isolate or specimen submission. 



|Recommended Tests|

Recommended Tests



Real-time RT-PCR for influenza A, B, H1, H3 at a State Health Department Laboratory is recommended. Currently, swine-origin influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR. If reactivity of real-time RT-PCR for influenza A is strong (e.g. Ct <30) it is more suggestive of a novel influenza A virus. Confirmation as swine-origin influenza A (H1N1) virus is performed at CDC currently, but may be available in state public health laboratories soon.



|Other influenza tests|

Other influenza tests



Rapid influenza antigen test: Also, these tests have unknown sensitivity and specificity to detect human infection with swine-origin influenza A (H1N1) virus in clinical specimens, and have suboptimal sensitivity to detect seasonal influenza viruses. Therefore, a negative rapid test could be a false negative and should not be assumed a final diagnostic test for swine-origin influenza infection. 



Immunofluorescence (DFA or IFA): These tests can distinguish between influenza A and B viruses. A patient with a positive for influenza A by immunofluorescence may meet criteria for a suspected case. However, it is not possible to differentiate from seasonal influenza A viruses. Immunofluorescence depends upon the quality of a clinical specimen, operator skills, and has unknown sensitivity and specificity to detect human infection with swine-origin influenza A (H1N1) virus in clinical specimens. Therefore, a negative immunofluorescence could be a false negative and should not be assumed a final diagnostic test for swine-origin influenza infection. 



Viral culture: Isolation of swine-origin influenza A (H1N1) virus is diagnostic of infection, but may not yield timely results for clinical management. A negative viral culture does not exclude infection with swine-origin influenza A (H1N1) virus.



---------------------------------------------------------------------------------------------------------------------------

~Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza~

Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza





Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting 



This document provides interim guidance for healthcare facilities (e.g., hospitals, long-term care and outpatient facilities, and other settings where healthcare is provided) and will be updated as needed.



|Background|

Background



To date, human cases of swine influenza A (H1N1) virus infection have been confirmed in residents of several U.S. states and Mexico (for the most up-to-date list please see http://www.cdc.gov/swineflu/). Investigations of these cases suggest that on-going human-to-human swine influenza A (H1N1) virus is occurring. Illness signs and symptoms have consisted of influenza-like illness - fever and respiratory tract illness (cough, sore throat, runny nose), headache, muscle aches - and some cases have had vomiting and diarrhea. Cases of severe respiratory disease, including fatal outcomes, have been reported.



The swine influenza A (H1N1) virus that has infected humans in the U.S. and Mexico is a novel influenza A virus that has not previously been identified in North America. This virus is resistant to the antiviral medications amantadine and rimantadine, but is sensitive to oseltamivir and zanamivir.



I|mplementation of Respiratory Hygiene/Cough Etiquette|

Implementation of Respiratory Hygiene/Cough Etiquette



To prevent the transmission of all respiratory infections in healthcare settings, including swine influenza A (H1N1), Respiratory Hygiene/Cough Etiquette infection control measures (see http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm) should be implemented at the first point of contact with a potentially infected person. They should be incorporated into infection control practices as one component of Standard Precautions.



Healthcare facilities should establish mechanisms to screen patients for signs and symptoms of febrile respiratory illness who are presenting to any point of entry to the facility for care or making appointments to be seen at the facility. Provisions should be made to allow for prompt segregation and assessment of symptomatic patients.



|Implementation of facility contingency plans|

Implementation of facility contingency plans



The current situation with swine flu in the United States is evolving quickly. Staff in healthcare settings should monitor http://www.cdc.gov/swineflu and state and local health department websites for the latest information. Healthcare facilities should be reviewing and making plans to implement their facility contingency response and/or pandemic response plans. This should include making plans for managing increasing patient volume and potential staffing limitations.



|Interim Infection Control Recommendations|

Interim Infection Control Recommendations



If the patient is presenting in a community where swine influenza A (H1N1) transmission is occurring (based upon information provided by state and local health departments), these infection control recommendations should apply to all patients with febrile respiratory illness (defined as fever [greater than 37.8ø Celsius] plus one or more of the following: rhinorrhea or nasal congestion; sore throat; cough).



If the patient is presenting in a community without swine influenza A (H1N1) transmission, these infection control recommendations should apply to those patients with febrile respiratory illness AND:



* close contact with a person who is a confirmed, probable, or suspected case of swine influenza A (H1N1) virus infection, within the past 7 days OR

* travel to a community either within the United States or internationally where there are one or more confirmed swine influenza A (H1N1) cases within 7 days



As the situation evolves, the ability to use epidemiologic links to identify potentially infectious patients may be lost and these recommendations may need to be applied to all patients with febrile respiratory illness. This situation will be monitored, and these guidelines will be updated as needed.



|Infection Control of Ill Persons in a Healthcare Setting|

Infection Control of Ill Persons in a Healthcare Setting



Screening of patients presenting to medical facilities



Patient placement and transport



Any patients who are confirmed, probable or suspected cases and present for care at a healthcare facility should be placed directly into individual rooms with the door kept closed. Healthcare personnel interacting with the patients should follow the infection control guidance in this document. For the purposes of this guidance, healthcare personnel are defined as persons, including employees, students, contractors, attending clinicians, and volunteers, whose activities involve contact with patients in a healthcare or laboratory setting.



Procedures that are likely to generate aerosols (e.g., bronchoscopy, elective intubation, suctioning, administering nebulized medications), should be done in a location with negative pressure air handling whenever feasible. An airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. Facilities should monitor and document the proper negative-pressure function of AIIRs, including those in operating rooms, intensive care units, emergency departments, and procedure rooms.



Procedures for transport of patients in isolation precautions should be followed. Facilities should also ensure that plans are in place to communicate information about suspected cases that are transferred to other departments in the facility (e.g., radiology, laboratory) and other facilities. The ill person should wear a surgical mask to contain secretions when outside of the patient room, and should be encouraged to perform hand hygiene frequently and follow respiratory hygiene / cough etiquette practices.



Limitation of healthcare personnel entering the isolation room



Healthcare personnel entering the room of a patient in isolation should be limited to those performing direct patient care.



Isolation precautions



Standard and Contact precautions plus eye protection should be used for all patient care activities for patients being evaluated or in isolation for swine influenza A (H1N1) (i.e., including all healthcare personnel who enter the patient's room). Maintain adherence to hand hygiene by washing with soap and water or using alcohol-based hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. Nonsterile gloves and gowns along with eye protection should be donned upon room entry. (See http://www.cdc.gov/ncidod/dhqp/ppe.html)



Respiratory protection: All healthcare personnel who enter the rooms of patients in isolation for swine influenza should wear a fit-tested disposable N95 respirator or equivalent (e.g., powered air purifying respirator)*. Respiratory protection should be donned upon room entry.



Note that this recommendation differs from current infection control guidance for seasonal influenza, which recommends that healthcare personnel wear surgical masks for patient care. The rationale for the use of respiratory protection is that a more conservative approach is needed until more is known about the specific transmission characteristics of this new virus. This recommendation is also outlined in the in the in the October 2006 "Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic" http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.html.



Management of visitors



Limit visitors to patients in isolation for swine influenza A virus (H1N1) infection to persons who are necessary for the patient's emotional well-being and care. Visitors who have been in contact with the patient before and during hospitalization are a possible source of swine influenza A virus (H1N1). Therefore, schedule and control visits to allow for appropriate screening for acute respiratory illness before entering the hospital and appropriate instruction on use of personal protective equipment and other precautions (e.g., hand hygiene, limiting surfaces touched) while in the patient's room. Visitors should be instructed to limit their movement within the facility.



Visitors may be offered a gown, gloves, eye protection, and respiratory protection (i.e., N95 respirator) and should be instructed by healthcare personnel on their use before entering the patient's room. 



Duration of precautions



Isolation precautions should be continued for seven (7) days from symptom onset or until the resolution of symptoms, whichever is longer.



Persons with swine influenza A (H1N1) virus infection should be considered potentially contagious from one day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might be contagious for longer periods.



Surveillance of healthcare personnel



In communities where swine influenza A (H1N1) virus transmission is occurring, healthcare personnel should be monitored daily for signs and symptoms of febrile respiratory illness. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.



In communities without swine influenza A (H1N1) virus transmission, healthcare personnel working in areas of a facility where there are patients being assessed or isolated for swine influenza infection should be monitored daily for signs and symptoms of febrile respiratory infection. This would include healthcare personnel exposed to patients in an outpatient setting or the emergency department. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.



Healthcare personnel who do not have a febrile respiratory illness may continue to work. Asymptomatic healthcare personnel who have had an unprotected exposure to swine influenza A (H1N1) also may continue to work if they are started on antiviral prophylaxis. Interim guidance on antiviral recommendations for close contacts of patients with confirmed or suspected swine influenza A (H1N1) virus infection can be found at http://www.cdc.gov/swineflu/recommendations.htm.



Management of ill healthcare personnel



Healthcare personnel should not report to work if they have a febrile respiratory illness.

In communities where swine influenza virus transmission is occurring, healthcare personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.



In communities without swine influenza virus transmission, healthcare personnel who develop a febrile respiratory illness and have been working in areas of the hospital where swine influenza patients are present, should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.



In communities where swine influenza virus transmission is not occurring, healthcare personnel who develop febrile respiratory illness and have not been in areas of the facility where swine influenza patients are present should follow facility guidelines on returning to work.



Stewardship of personal protective equipment and antivirals



Facilities should implement plans to ensure appropriate allocation of personal protective equipment, including N95 respirators, and antivirals.



Environmental infection control



Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. Management of laundry, utensils and medical waste should also be performed in accordance with procedures followed for seasonal influenza. More information can be found at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.



Facility access control



Facilities should have signage at entry points instructing patients and visitors about hospital policies, including the need to notify staff immediately if they have signs and symptoms of febrile respiratory illness. Facilities in communities where swine influenza transmission is occurring should limit points of entry to the facility..



Administration of the current 2008-2009 seasonal influenza vaccine



It is not anticipated that the seasonal influenza vaccine will provide protection against the swine flu H1N1 viruses. However, in some parts of the country, seasonal influenza viruses are still circulating. Influenza vaccination is effective against these seasonal viruses and should continue to be given to unvaccinated patients in areas where seasonal influenza cases are still occurring.



*Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Information on respiratory protection programs and fit test procedures can be accessed at http://www.osha.gov/SLTC/etools/respiratory. Staff should be medically cleared, fit-tested, and trained for respirator use, including: proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use.



Additional information on N95 respirators and other types of respirators may be found at: http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/

respfact.html, and at http://www.fda.gov/cdrh/ppe/masksrespirators.html.






@$





 


@$





 







 