HHS has declared a public health emergency in response to a swine flu outbreak that has resulted in 40 confirmed human cases in five states. Meanwhile, the World Health Organization, or WHO, today raised its influenza pandemic alert from phase 3 to phase 4, after cases of the illness were confirmed in Canada and Spain.
In addition, the CDC now is advising Americans to avoid nonessential travel to Mexico, which has more than two dozen laboratory-confirmed cases and hundreds more under investigation.
CDC Issues Swine Flu Guidance After 40 Cases Confirmed in Five States
Physicians Asked to Collect Samples for Testing
By David Mitchell
4/27/2009
The AAFP also has gone on the offensive in response to this health emergency, calling on members to remain vigilant for suspected cases in their communities, stay abreast of updates coming from national and international health agencies, and maintain close contact with their state and local health departments during this evolving situation.
CDC Gives Status Briefing on Outbreak
Richard Besser, M.D., acting director of the CDC, said today in a press briefing that of the 40 confirmed U.S. cases, there was only one known hospitalization, and all patients have recovered or are recovering. The illness is spreading through person-to-person contact.
"As we continue to look, I expect we will see cases in other parts of the country, and I would fully expect that we'll see a broader range in the severity of infection," he said. "Thankfully, so far, we've not seen severe disease in this country as has been seen in Mexico."
In addition to the 40 confirmed U.S. cases -- in California, Kansas, New York, Ohio and Texas -- Besser said that the CDC has confirmed 26 cases of swine flu in humans in Mexico, a figure he acknowledged was only a small fraction of the illnesses the country is dealing with.
According to an April 26 WHO report, suspected swine flu cases have been reported in 19 of Mexico's 32 states. On that same date, Health Canada reported six confirmed cases in that country, and the first European case has been confirmed in Spain. Suspected cases also have been reported in France, Israel and New Zealand.
Anne Schuchat, M.D., interim deputy director for the CDC's Science and Public Health Program, said the viral infection presents with high fever, respiratory symptoms, and nausea and vomiting that is more severe than is typically seen with seasonal flu. Respiratory symptoms may include cough and sore throat.
CDC officials said physicians should consider swine flu in the differential diagnosis of patients with febrile respiratory illness. If the illness is suspected, clinicians should obtain a respiratory swab for testing, refrigerate it, and promptly contact their state or local health departments to facilitate transport and timely diagnosis at a state public health laboratory.
"Everyone has a responsibility," Besser said, "and it's been absolutely incredible to see people around the country standing up and taking responsibility and doing the things they need to do to reduce the impact of this outbreak. I really want to recognize the incredible work being done by the medical provider community and the public health community."
"As we continue to look, I expect we will see cases in other parts of the country, and I would fully expect that we'll see a broader range in the severity of infection," he said. "Thankfully, so far, we've not seen severe disease in this country as has been seen in Mexico."
In addition to the 40 confirmed U.S. cases -- in California, Kansas, New York, Ohio and Texas -- Besser said that the CDC has confirmed 26 cases of swine flu in humans in Mexico, a figure he acknowledged was only a small fraction of the illnesses the country is dealing with.
According to an April 26 WHO report, suspected swine flu cases have been reported in 19 of Mexico's 32 states. On that same date, Health Canada reported six confirmed cases in that country, and the first European case has been confirmed in Spain. Suspected cases also have been reported in France, Israel and New Zealand.
Anne Schuchat, M.D., interim deputy director for the CDC's Science and Public Health Program, said the viral infection presents with high fever, respiratory symptoms, and nausea and vomiting that is more severe than is typically seen with seasonal flu. Respiratory symptoms may include cough and sore throat.
CDC officials said physicians should consider swine flu in the differential diagnosis of patients with febrile respiratory illness. If the illness is suspected, clinicians should obtain a respiratory swab for testing, refrigerate it, and promptly contact their state or local health departments to facilitate transport and timely diagnosis at a state public health laboratory.
"Everyone has a responsibility," Besser said, "and it's been absolutely incredible to see people around the country standing up and taking responsibility and doing the things they need to do to reduce the impact of this outbreak. I really want to recognize the incredible work being done by the medical provider community and the public health community."
The Academy Calls on Members to Act
Also today, the AFFP released a statement urging its members to take the following steps:
- follow the clinical guidance for swine flu issued by the CDC;
- stay updated regarding this rapidly changing situation using links to the CDC's swine flu Web site, the federal pandemic flu Web site, and the WHO Web site;
- work with state and local health departments to address this growing health problem;
- educate their patients and office staff about how they can lessen their risk of infection; and
- prepare to deal with the effects of a possible pandemic, such as illness among practice staff, closed schools and other contingencies.
"As community-based physicians caring for the entire family, family physicians are on the front line in combating this swine flu," the AAFP statement says. "Through surveillance, diagnosis and treatment, the specialty of family medicine will act to limit the impact of this disease while continuing to provide care for the other health problems of patients in the patient-centered medical home."
CDC Issues Treatment and Prophylaxis Guidance
Antiviral treatment is recommended for patients with suspected swine influenza A (H1N1) virus infection. Antiviral treatment with either zanamivir alone or with a combination of oseltamivir and either amantadine or rimantadine should be initiated as soon as possible after symptom onset.
To that end, Besser said the CDC is releasing about 11 million courses of antiviral drugs from the CDC's Strategic National Stockpile to the states.
To that end, Besser said the CDC is releasing about 11 million courses of antiviral drugs from the CDC's Strategic National Stockpile to the states.
Recommended Antiviral Medications
- Oseltamivir = Tamiflu
- Zanamivir = Relenza
- Amantadine = Symmetrel
- Rimantadine = Flumadine
According to the CDC guidance, swine flu is sensitive to zanamivir and oseltamivir, but is resistant to amantadine and rimantadine. However, seasonal influenza -- which has similar symptoms -- is still circulating at low levels in the United States. Human influenza A (H3N2) is resistant to amantadine and rimantadine, but is sensitive to oseltamivir and zanamivir; human influenza A (H1N1) is resistant to oseltamivir but is sensitive to amantadine, rimantadine and zanamivir.
Antiviral chemoprophylaxis against exposure to potential exposure to swine flu (pre-exposure or post-exposure) with either oseltamivir or zanamivir is recommended for several groups, including
Antiviral chemoprophylaxis against exposure to potential exposure to swine flu (pre-exposure or post-exposure) with either oseltamivir or zanamivir is recommended for several groups, including
- close contacts of a confirmed or suspected swine flu case who are at high risk for influenza complications,
- certain recent travelers to Mexico,
- border workers at high risk for flu complications, and
- health care workers or public health workers who had unprotected close contact with an ill confirmed case of swine influenza A (H1N1) virus infection during the disease's infectious period.
The CDC guidance also says antiviral chemoprophylaxis can be considered for certain other individuals.
Treatment options are limited for some, however. Oseltamivir, zanamivir, amantadine and rimantadine all are pregnancy category C medications, meaning no clinical studies have been conducted to assess the safety of these medications in pregnant women.
"Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, these four drugs should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus," says the CDC. However, the agency notes, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among their infants.
According to family physician and infectious disease expert Doug Campos-Outcalt, M.D., M.P.A., "There might be instances when using the medicine for a seven-day period might be beneficial even though it hasn't been approved for use during pregnancy."
Campos-Outcalt, who is associate head of the department of family and community medicine at the University of Arizona College of Medicine in Phoenix, said that basic hygiene practices, such as covering the nose and mouth when coughing or sneezing; washing hands frequently; and avoiding touching the eyes, nose or mouth, are especially important during communicable disease outbreaks.
"I'd be saying to patients, 'These are good ideas all the time,'" he told AAFP News Now. "'At this time, it's an even better idea.'"
Campos-Outcalt, the AAFP's liaison to the CDC's Advisory Committee on Immunization Practices, said physicians can take precautions such as asking patients who present with flu-like symptoms to wear a mask and/or completely cover their mouth and nose when coughing or sneezing. He also said practices could consider physically separating patients with flu symptoms from other patients during regular office hours or offering extended hours specifically for flu patients.
Physicians may wish to consider other preparedness steps, said Campos-Outcalt, such as
Treatment options are limited for some, however. Oseltamivir, zanamivir, amantadine and rimantadine all are pregnancy category C medications, meaning no clinical studies have been conducted to assess the safety of these medications in pregnant women.
"Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, these four drugs should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus," says the CDC. However, the agency notes, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among their infants.
According to family physician and infectious disease expert Doug Campos-Outcalt, M.D., M.P.A., "There might be instances when using the medicine for a seven-day period might be beneficial even though it hasn't been approved for use during pregnancy."
Campos-Outcalt, who is associate head of the department of family and community medicine at the University of Arizona College of Medicine in Phoenix, said that basic hygiene practices, such as covering the nose and mouth when coughing or sneezing; washing hands frequently; and avoiding touching the eyes, nose or mouth, are especially important during communicable disease outbreaks.
"I'd be saying to patients, 'These are good ideas all the time,'" he told AAFP News Now. "'At this time, it's an even better idea.'"
Campos-Outcalt, the AAFP's liaison to the CDC's Advisory Committee on Immunization Practices, said physicians can take precautions such as asking patients who present with flu-like symptoms to wear a mask and/or completely cover their mouth and nose when coughing or sneezing. He also said practices could consider physically separating patients with flu symptoms from other patients during regular office hours or offering extended hours specifically for flu patients.
Physicians may wish to consider other preparedness steps, said Campos-Outcalt, such as
- maintain a stock of supplies;
- keep staff healthy, possibly by offering antiviral prophylaxis; and
- consider providing prophylaxis to patients and their close contacts by phone or e-mail.
CDC Evaluating Next Steps
According to Besser, the CDC is working on a vaccine seed strain, but no decision has been made to manufacture a vaccine to prevent infection with the new virus.
Such a process could take months, said Schuchat, given that the virus encompasses genetic pieces from four different virus sources: North American avian influenza virus, North American swine influenza virus, and human influenza viruses from Asia and Europe.
"This particular genetic combination of swine influenza virus segments has not been recognized before in the U.S. or elsewhere," she said.
Such a process could take months, said Schuchat, given that the virus encompasses genetic pieces from four different virus sources: North American avian influenza virus, North American swine influenza virus, and human influenza viruses from Asia and Europe.
"This particular genetic combination of swine influenza virus segments has not been recognized before in the U.S. or elsewhere," she said.
