Novel Influenza A (H1N1) 09

Transcription

1 orthern Regional Health Coordination Centre RHCC c/- Level 5, Administration Auckland City Hospital 2 Park Road, Grafton Private Bag Auckland Tel: Ext Fax: Internal Fax: nrhcceocm@adhb.govt.nz Novel Influenza A (H1N1) 09 Health Professional Advice for the Northern Region Version: 6 July 2009, 1000 hrs Purpose This document has been prepared by the Northern Region Health Coordination Centre (NRHCC). Its purpose is to update public health staff, primary care providers, A&M clinics, emergency clinicians and departments, and infectious diseases clinicians and departments on the management of the evolving influenza A, H1N1 situation. It contains all current information. Please dispose of earlier advice from Auckland Regional Public Health Service (ARPHS) about this matter (e.g. Call Centre Advice, Call Centre FAQs, Primary Care Clinical Briefings). Notes Given the frequency of advice from the Ministry of Health, the desire to align processes in Auckland and Northland with that advice, and the need to provide some information of specific relevance to health practitioners working within the Northern region, this advice is a combination of Ministry of Health advice and advice developed by the NRHCC for the Northern region. The source for each section of advice is kept in a reference document held by the NRHCC. Information likely to be relevant to all health professionals is presented first. Information specific to primary care and Emergency Departments is at the back of this document. Key phone numbers Healthline: For members of the public to obtain health information and advice GP Swine Flu Support Line: For GPs and primary care practice staff to obtain clinical support and advice on swine flu 0800 FLU LINE ( ): ARPHS call centre number for advice on public health measures such as social distancing, and to support cluster control activity Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 1 of 14

2 Influenza A (H1N1) 09 Health Professional Advice 1.0 CHARACTERISTICS OF INFLUENZA A (H1N1) 09 INFECTION 1.1 Infectious Period 1 day before until 7 days after onset of symptoms 1.2 Incubation period Usually within 72 hours, but up to 4 days 1.3 Survival of Virus The influenza virus can survive on surfaces while secretions are moist (i.e. until they dry). Recommend that any potentially affected surfaces are cleaned regularly with diluted bleach and that any contaminated items (e.g. used tissues) are promptly and properly disposed of and hands washed. Further advice: refer to ARPHS Cleaning Guidance for Households with Cases of Influenza A (available CASE DEFINITIONS FOR NOVEL INFLUENZA A (H1N1)* * Also termed non-seasonal influenza or influenza A (H1N1) 09 From Ministry of Health National Health Coordination Centre: Guidance on the diagnosis and management of Novel Influenza A (H1N1) 09 in the Pandemic Management phase No June 2009, Version 2. Notes as follows: The purpose of the new case definitions is: To assist with ongoing surveillance and international reporting obligations To assist with clinical management decisions To assist in public health or infection control responses. There is no longer a suspected case definition as there is community transmission in several places in New Zealand and a travel history is no longer a prerequisite for having suspected Novel Influenza A (H1N1) Confirmed case A confirmed case of novel influenza A H1N1 09 virus infection is defined as a person with laboratory confirmed novel influenza A H1N1 09 virus infection by one or more of the following tests: real-time RT-PCR viral culture four-fold rise in novel influenza A H1N1 09 virus specific neutralising antibodies 2.2 Probable case A probable case of novel influenza A H1N1 09 virus infection is defined as a person with an influenza like illness* who has a strong epidemiological link to a confirmed case or defined cluster. * Influenza-like illness: (i) history of fever, chills and sweating or clinically documented fever 38 C, plus (ii) cough or sore throat 2.3 Close contact A close contact is defined as someone who has cared for, lived with, or had direct contact with respiratory secretions or bodily fluids of a probable or confirmed case. Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 2 of 14

3 3.0 DIAGNOSIS OF NOVEL INFLUENZA A(H1N1) CASES IN THE MANAGE IT PANDEMIC PHASE 3.1 Key points Diagnosis will be based largely on history and clinical presentation. In most people, it will not be possible to distinguish Novel Influenza A (H1N1) 09 infection from seasonal influenza. However, management will be similar in most cases, in particular for people with mild to moderate disease. Routine swabbing in primary care is not recommended. Health workers should prioritise taking nasopharyngeal swabs according to the indications listed below. 3.2 Who to swab Testing should be limited to the following three indications: As part of the national influenza sentinel surveillance programme Where clinically indicated for individuals (see 3.3) Where indicated for public health or infection control reasons (see 3.4) 3.3 Clinical indications for testing The Ministry of Health recommends the following may be clinical indications for testing, if required to inform clinical management decisions Patients with severe clinical influenza-like illness (see 5.3), regardless of whether they are admitted to hospital Hospitalised patients with upper or lower respiratory tract symptoms Symptomatic people at high risk of influenza-related complications or more likely to require hospitalisation (indications as for treatment: see 5.5). 3.4 Public health or infection control indications for testing The Ministry of Health recommends testing if there is a public health or infection control rationale in the following situations: People who live or work in high risk institutions (indications as for treatment: see 5.6) For the purpose of cluster identification. In this context, it is likely to be sufficient to test a sample of close contacts in the identification of clusters. The extent of testing is at the discretion of the local public health unit.. For the purposes of infection control investigation. Infection control indications may include people who work in health care settings and essential services. 3.5 Process for taking swabs, if indicated Nasopharyngeal swabs for novel influenza A H1N1 09 testing are to be taken within the first 48 hours of symptom onset for people presenting with influenza-like illness [defined as a history of fever, rigors, chills and sweating or clinically documented fever 38 C plus cough or sore throat]. Do NOT take swabs from people who meet any of the following criteria: adults who have commenced twice-daily treatment course of antiviral medication Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 3 of 14

4 children who have been on a twice-daily treatment course of antiviral medication for 48 hours For contacts on once-daily prophylaxis with antiviral medication who develop symptoms, a swab, if indicated, should be taken within 48 hours of commencing antiviral medication. Arrange for two pernasal nasopharyngeal viral swabs to be done (one from each nostril). Rationale for using two nasopharyngeal swabs (instead of one nasopharyngeal and one throat swab): Evidence from the literature that there is a better recovery rate for influenza viruses from nasopharyngeal swabs than from throat swabs The amount of specimen collected is the limiting factor it is essential to obtain a good quality specimen Two nasopharyngeal swabs should maximise the amount of specimen, with both swabs collected from the optimum site Use the currently supplied DML viral swab kits: Swab one nostril with the larger swab run the swab along the base of the nasal cavity as far as it will go (without causing too much discomfort) Swab the nasopharynx using the smaller swab through the second nostril If the larger swab is too large (e.g. in children, people with small noses, etc) use a smaller swab for each nostril (i.e. use the smaller swabs out of two swab kits) Both swabs should be placed together into one vial of viral transport medium If the health worker is not confident in their ability to take a pernasal nasopharyngeal swab then a nasal swab can be substituted. Swabs should be double bagged, and the lab request form should be placed in the outer pocket of the bag (i.e. do not place the lab request form inside the bag with the swabs). Only take swabs where this does not interfere with clinical management Primary care refer to the current Primary Care Algorithm (30th June Manage It Version 2 at the time this advice was distributed). Write clearly on the lab form probable case of novel Influenza A (H1N1). Primary care refer to section 7.3 for further information on process. ED and ID send swabs to LabPlus (for PCR testing) with the form indicating Possible Novel Influenza. There is no need to phone the public health unit for authorisation. When taking nasopharyngeal swabs wear full PPE (N95 mask, visor/goggles, gown, and gloves). Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 4 of 14

5 4.0 NON-PHARMACOLOGIC MANAGEMENT OF PROBABLE AND CONFIRMED CASES 4.1 Key point Most cases will be able to self manage at home and should be encouraged to do so by being provided with appropriate health advice. 4.2 Isolation Advise cases who have not received antiviral treatment to remain isolated at home while infectious, until the longer of the following has occurred: Seven days have elapsed since onset of symptoms AND asymptomatic OR 24 hours after resolution of symptoms Cases who receive antiviral treatment (see 5.2) may leave isolation after the following intervals: Persons aged over five years of age: may leave isolation after receiving 72 hours of antiviral treatment Children aged five years or younger: may leave isolation after receiving 5 days of treatment, as excretion can be greater and prolonged in this age group. However, in either group if still significantly symptomatic and as a common sense measure the case should be advised to remain in isolation until they are feeling well Isolation means not leaving the home except to seek medical care. This means avoiding normal activities, including work, school, travel, shopping, social events, and public gatherings. 4.3 Hand Hygiene Persons who are unwell and their caregivers or household members should be advised to maintain good hand hygiene, as follows: Wash hands well with soap and water for 20 seconds (especially before eating, after coughing or sneezing, and after going to the toilet) AND dry hands thoroughly for 20 seconds, preferably with a disposable hand towel Alternately use an antiseptic hand gel for 20 seconds Keep your hands away from your mouth, nose, ears and eyes 4.4 Cough and sneeze etiquette People who are coughing or sneezing should be kept at home to avoid spread of any flu type to other people. To reduce the risk of spread of any type of influenza, provide the following advice: Cough or sneeze into a tissue, or into your own elbow Cover your nose and mouth when blowing your nose, use a tissue Only spit into a tissue or into the toilet, do not spit in public places Immediately throw the tissue into a rubbish bin Try to stay 1 metre away from people who are coughing or sneezing Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 5 of 14

6 Use Hand Hygiene after coughing or sneezing 4.5 Cleaning guidance for households with cases of influenza A Please see ARPHS Cleaning Guidance for Households with Cases of Influenza A (available from ARPHS website Steps to lessen spread of flu in the home Provide advise to household members of those unwell with influenza on ways to protect others in the household, as follows: Keep the sick person in a room separate from the common areas of the house. Keep the door to the sick person s room closed (check to ensure small children are safe). If possible, sick persons should use a separate bathroom. This bathroom should be cleaned daily with household disinfectant. Have everyone in the household clean their hands often, using soap and water or an alcohol-based hand rub. Wash hands for 20 seconds, then dry hands for 20 seconds. Use paper towels for drying hands or dedicate cloth towels to each person in the household (for example, by using different coloured towels). If possible, have only one adult in the home take care of the sick person Avoid having pregnant women care for the sick person Give consideration to maintaining good ventilation in shared household areas (e.g., keeping windows open in restrooms, kitchen, bathroom, etc.). 4.7 When to seek medical attention Persons with influenza-like illness or their caregivers should be advised to seek medical advice from Healthline ( ) or phone their family doctor if the person unwell has: Been unwell for 3 or 4 days and are not getting any better or are feeling worse A high temperature that is not responding to attempts to reduce it Difficulty breathing or shortness of breath Pain or pressure in the chest or stomach Been coughing up bloody or green phlegm Blue skin around the lips and/or blue skin on finger tips Severe pain in the ear/s Severe vomiting Difficulty waking up, disorientation or confusion Been experiencing fits or uncontrollable shaking Started to feel better but then gets a high fever and starts to feel unwell again Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 6 of 14

7 5.0 ANTIVIRAL TREATMENT OF PROBABLE AND CONFIRMED CASES 5.1 Key points The Ministry of Health recommends the prudent use of antivirals in treating novel influenza A H1N1 09 virus infection Treatment should start immediately where indicated, rather than waiting for the results of testing if this has been done. Treatment, if commenced, should begin within the first 48 hours of symptom onset for people presenting with influenza-like illness [defined as a history of fever (rigors, chills, sweating) or clinically documented fever 38 C, plus cough or sore throat]. Only consider initiating antiviral treatment after 48 hours of the onset of symptoms for people with severe clinical illness, where possible in discussion with an infectious disease physician. For child (aged 5 years or less) cases, treatment can be initiated up to 5 days from the onset of symptoms. 5.2 Relative indications for antiviral treatment The Ministry of Health recommends that antiviral use should be confined to the following groups: Patients with severe clinical influenza-like illness, regardless of whether they are admitted to hospital: see 5.3. Hospitalised patients with upper or lower respiratory tract symptoms: see 5.4. Symptomatic people at high risk of influenza-related complications or more likely to require hospitalization: see 5.5. People who live or work in high risk institutions: see 5.6 As part of cluster and/or infection control, where appropriate: see Patients with severe clinical influenza-like illness (regardless of whether they are admitted to hospital) Symptomatic patients should be treated as with seasonal flu. People with moderately-severe and severe illness should be referred to hospital. A sepsis or pneumonia assessment tool, such as the SIRS (see below) may be useful in deciding who to treat and/or refer to hospital. This should not replace clinical judgment but rather support and/or confirm it. Note that the CRB-65 was provided in previous versions of this advice but has been removed as it is less suitable in this role Systemic Inflammatory Response Syndrome (SIRS) These signs may indicate significant physiologic disruption, including sepsis. White cell count is the fourth criterion, but this is not included for this purpose. SIRS can be diagnosed when two or more of the following criteria are fulfilled: Temperature 38 degrees Celsius Heart Rate >90/min Respiratory Rate >20/min Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 7 of 14

8 5.4 Hospitalised patients with upper or lower respiratory tract symptoms This category includes: people who are hospitalised for any reason, but who are symptomatic with an influenza-like illness hospitalised patients who are close contacts of a confirmed case 5.5 Symptomatic people at high risk of influenza-related complications This category includes: People who are immune compromised or suppressed due for example to transplantation, haematological and solid organ malignancy on chemotherapy/radiotherapy, HIV, autoimmune disorders, or at risk of white cell suppression due to use of medicines such as clozapine. Pregnant women (see 5.8) Anyone aged over six months old with chronic medical conditions, such as: Severe or poorly controlled congestive heart failure Severe or poorly controlled chronic respiratory disease Severe asthmatics (e.g. people on oral steroids, high dose steroid inhalers, or steroids and long-acting beta-agonists) Renal replacement therapy (see Renal Dosing of Oseltamivir ) 5.6 People who live and work in high-risk institutions This category includes: Health care and other care providers in facilities and community settings who, through their activities, are capable of transmitting influenza to those at high risk of influenza complications People who provide services within closed or relatively closed settings to persons at high risk (e.g. prisons, early child care centres). People of any age who are residents of a nursing home and other chronic care facilities 5.7 Cluster control and infection control The extent of provision of antiviral treatment in these contexts is at the discretion of public health or infection control authorities as appropriate. 5.8 Directions for providing antiviral treatment if indicated (refer 5.2) Tamiflu is the first line antiviral treatment. The first dose should be given with food to reduce the incidence of nausea and vomiting. Relenza should only be used where Tamiflu cannot be taken or cannot be tolerated, or the case or contact has renal impairment. Indications for the use of Relenza instead of Tamiflu include: An inability to take or tolerate Tamiflu e.g. due to vomiting or diarrhoea Renal failure. Please see medicine data sheets: Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 8 of 14

9 To access Ministry of Health Tamiflu stockpile refer to the current Primary Care Algorithm (30th June Manage It Version 2, at the time this advice was distributed) Pregnant women: Pregnant women appear to have higher rates of hospitalisation with influenza for variety of reasons and fever in the first trimester is associated with twice the rate of neural tube defects in the fetus. Therefore both antipyretics and antivirals may be useful. Influenza close to the time of delivery poses extra challenges for maternal and newborn health, as well as challenges to infection prevention in the delivery suite. The Ministry s Pandemic Influenza Technical Advisory Group recommends early administration with either oseltamavir (Tamiflu) or Zanamavir (Relenza) when indicated, and oseltamavir may be more easily accessed. Neither medicine is contraindicated during pregnancy, however there is limited information related to their use. Whereas preclinical studies suggest that the risks are low, their potential to cause fetal toxicity or malformations in humans is currently unknown; therefore it is recommended that they should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. A local obstetric or infectious diseases specialist should be consulted where there are concerns. 5.9 Tamiflu Adults Treatment of cases: Tamiflu 75mg BD for 5 days unless contraindicated Prophylaxis of close contacts: Tamiflu 75mg OD for 10 days unless contraindicated For people who cannot take medication capsules go to Further information available at Further information available from GP Swine Flu support line: Children Go to Further information available at to Further information available from GP Swine Flu support line: Contraindications Hypersensitivity to oseltamivir phosphate or any component of the product [from Side effects Usually minimal. Commonly reported side effects include nausea, vomiting, headache and rash. Further information available at Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 9 of 14

10 5.10 Relenza An alternative treatment for Influenza A (H1N1): may be particularly useful for adults and children 5 years and over who have gastrointestinal side effects with Tamiflu since it is delivered by inhalation. Teatment dose: 2 x 5mg inhalations twice a day for 5 days. Prophylactic dose: 2 x 5mg inhalations one daily for 10 days Further information available at: or contact GP Swine Flu support line: Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 10 of 14

11 6.0 MANAGEMENT OF CLOSE CONTACTS OF PROBABLE OR CONFIRMED CASES OF NOVEL INFLUENZA A (H1N1) Key point The Ministry of Health does not currently recommend the routine use of antivirals for pre- or post-exposure prophylaxis. However, there may be situations where postexposure prophylaxis is indicated e.g. for essential workers and hospital staff where there have been significant breaches of PPE, on a case by case basis. If considering the post-exposure prophylactic use of antiviral medication (Tamiflu or Relenza), this should be discussed with your local Public Health Unit. 6.2 Management of symptomatic contacts For contacts who currently have respiratory symptoms or develop respiratory symptoms within 4 days of last contact: consider to be probable cases and manage as described in sections 4.0 and Health information Provide health information to households, schools, workplaces or other groups as appropriate. 6.4 Institutions with high-risk contacts In institutions where there is a likelihood of transmission to contacts with a high risk of influenza-related complications (e.g. health care, aged care, residential community homes, prisons): Asymptomatic contacts do not need quarantine Provide health information Undertake a risk assessment and consider the need for post-exposure prophylaxis of asymptomatic contacts with antiviral treatment For contacts who currently have respiratory symptoms or develop respiratory symptoms within 4 days of last contact: consider to be probable cases and manage as described in sections 4.0 and Contacts exposed onboard aircraft or ships No quarantine or work stand down period required. 6.6 Post-exposure prophylaxis Contacts indicated for post-exposure prophylaxis are to receive 1 x 75 mg Tamiflu capsule daily for 10 days or Relenza 2 x 5mg, (2 inhalations) once a day for 10 days as prophylaxis. For paediatric doses consult the relevant medicine data sheet. 7.0 OTHER ADVICE 7.1 Advice for patients with influenza symptoms intending to seek medical care People with influenza like symptoms who are intending to see their GP or attend at an emergency department should be advised to: Use a CBAC or special clinic if these have been established Call GP first to ensure that assessment is undertaken in isolation When presenting to GP practice or Emergency Department, identify themselves for immediate isolation (preferably arrange entry by a separate entrance) Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 11 of 14

12 Practice social distancing (staying >1 metre away from others) e.g. avoid hand shaking etc Perform hand hygiene Put a mask on if available otherwise cover mouth/nose with tissue when coughing/sneezing 7.2 PPE for clinical staff (NZ MOH PPE guidelines) In the NZ Pandemic Influenza Action plan the NZ Ministry of Health has identified 4 categories of exposure risk, and recommends differing levels of PPE for each category (see Appendix 10) Lower/medium (green): people who can maintain > 1 m contact distance from those potentially infected. Apply hand hygiene, social distancing and adequate ventilation. Medium (yellow): people who may be unable to maintain > 1m contact distance. Apply the above AND a surgical mask AND gloves if direct contact is likely. Medium/higher (orange): people who cannot maintain at least 1 m contact distance. Apply the above measures, including gloves and gown. Higher (red): people who cannot maintain at least 1 m contact distance AND have a high likelihood of potential contact with aerolised respiratory secretions from invasive procedures. Apply above measures AND eye protection AND use particulate respirator/n95 mask instead of surgical mask. 7.3 Advice specific to primary care Booking patients When a patient contacts the practice, where possible reception staff should ask a triage question to ascertain the likelihood the patient has an influenza-like illness. For patients presenting with flu-like symptoms, or those who are concerned they have been in contact with someone with influenza A (H1N1) Display a notice at your entrance asking patients suffering flu-like symptoms to remain outside the practice and, for example: Use a specific doorbell ring Knock three times on the door Attract the attention of staff inside the practice This will allow staff members to undertake appropriate precautions. Suggested infection control precautions: Front-line staff to put on simple surgical mask Provide patient with simple surgical mask Where possible, escort the patient to a designated isolation area preferably through an external access way (i.e. not through the waiting room) Staff assessing the patient should follow standard practice procedures regarding infection control including wearing a simple surgical mask and gloves Always remember, strict hand hygiene, soap wash and/or alcohol hand rub. Any patient contact equipment remains in your isolation room and is either disposed of appropriately or put through standard disinfection process. Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 12 of 14

13 If you believe the patient needs emergency medical intervention please attend to these needs as quickly as possible. If bronchodilator therapy is required, use a spacer device accordingly (do not use nebulisation). Infection control after case has left CDC advises that influenza viruses may survive on hard surfaces such as benches and door knobs for 2 hours or more (and while moist). Surfaces can be cleaned using standard disinfectants such as bleach. Allow an interval of at least 30 minutes after wiping surfaces with bleach solution before resuming use of that space. If hospital admission required Please phone the on-call medical registrar at your usual referring hospital. (for Auckland City Hospital, call the ID registrar) Once accepted please contact hospital admissions advising them of patient details and alerting to infectious risk Arrange transport with St Johns and advising them of the infectious risk so they can take the necessary precautions Determine and record the patient s close contacts. Follow close contact guidance above. Swabs Swabs should only be taken where indicated: see section 0, Diagnosis of Novel Influenza A (H1N1) 09 in the Manage it Pandemic Phase Two pernasal nasopharyngeal swabs required (one from each side) see section on swab collection Use green flocked swabs, available on request from DML. Note that ARPHS is not distributing swabs to GPs If the GP doesn t have these swabs on hand then viral swabs (ie as used for herpes or influenza sentinel monitoring) may be used. Both pernasal nasopharyngeal swabs from the same patient may be placed in the same culture medium. Please DO NOT use wire swabs as these cannot be analysed Availability of viral swabs DML are providing viral swab kits to GPs to have on hand. Because of limited availability and large demand 2 packs will be provided per site per request. They will be delivered through usual DML mechanisms. Where should GPs send swabs? GPs can drop influenza swabs to DML labs OR for very urgent swabs, Co-op Taxis will collect the swabs from the GP practice and a taxi chit will be provided to the taxi driver at LabPlus (Auckland City Hospital) lab drop off GPs should contact LabPlus if they need further information about this. Responsibility for ongoing monitoring and care of home isolated cases Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 13 of 14

14 The primary care practice team is responsible for ongoing monitoring and care of cases being managed at home. 7.4 Advice specific to Emergency Departments Receiving patients When a patient comes into Emergency Department, where possible reception staff should ask a triage question to ascertain the likelihood the patient has an influenzalike illness. Display a notice at your entrance asking patients who have an influenza-like illness and who meet the case definition (see page 2) to observe social distancing (one metre rule) and to inform reception immediately. This will allow staff members to undertake appropriate precautions. Infection control precautions Place in single room informing Charge Nurse and SMO (or Senior Registrar). Wear gown, gloves and surgical mask when seeing patient. Strict hand hygiene and PPE disposal when leaving room. Novel Influenza A (H1N1): Health Professional Advice for the Auckland Region Page 14 of 14