Microsoft word - nycdohmh flu advisory - 11-28-07 _3_.doc

THE CITY OF NEW YORK
DEPARTMENT OF HEALTH AND MENTAL HYGIENE _______________________________________________________________ 2007 New York City Department of Health and Mental Hygiene
(NYC DOHMH) Health Advisory # 34: Influenza Update
• Influenza Advisory
o Three culture-confirmed influenza infections have been reported in NYC to date this
season. However, there is not yet evidence of widespread influenza activity based on
other surveillance systems in NYC.
o Persons who should receive an annual influenza vaccination include: all children aged 6
to 59 months, adults aged > 50 years, pregnant women, and persons aged > 6 months
with chronic medical conditions predisposing them to influenza-associated
complications, household contacts of those listed, all health care workers, and anyone
who wants to reduce their chances of getting the flu.
o This year, a record amount of influenza vaccine has been produced and distributed.
Vaccination should begin as soon as providers have vaccine and should continue
through June.
o DOHMH continues to request that pediatric providers report suspected or confirmed
influenza-related deaths in children < 18 years of age.
o Only oseltamivir or zanamivir should be used for prophylaxis or treatment of influenza.
Neither amantadine nor rimantadine should be used for influenza prophylaxis or
treatment because of concerns about antiviral resistance.

• H5N1 Avian Influenza Advisory
o Highly pathogenic avian influenza (H5N1) activity continues in both birds and humans
in Southeast Asia and Africa. Avian influenza activity has also been reported in birds in
East and Central Asia and in parts of Europe.
o DOHMH reminds providers to remain alert and report any suspected H5N1 avian
influenza cases among travelers returning from currently affected countries. Providers
should obtain a travel history from all patients with severe respiratory illness (e.g.,
pneumonia or acute respiratory distress syndrome) requiring hospitalization.
o Personal stockpiles of influenza antiviral medications are not recommended.
Please distribute to staff in the Departments of Critical Care, Emergency Medicine, Family
Practice, Geriatrics, Internal Medicine, Infectious Disease, Infection Control, Pediatrics,
Pulmonary Medicine and Laboratory Medicine
November 28, 2007 Dear Colleagues, With recent reports of the first culture-confirmed influenza infections in New York City this season, the New York City Department of Health and Mental Hygiene (DOHMH) would like to remind providers of the importance of influenza vaccination, especially in persons at high risk from complications secondary to influenza infection (http://www.nyc.gov/html/doh/downloads/pdf/chi/chi26-8.pdf), and of the need to Categories of urgency levels for NYC DOHMH Broadcast Notification System:
Health Alert: conveys the highest level of importance; warrants immediate action or attention
Health Advisory: provides important information for a specific incident or situation; may not require immediate action
Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action
report: 1) nosocomial outbreaks of febrile respiratory disease, 2) suspected or confirmed influenza-related
deaths in children aged < 18 years, and 3) suspected cases of avian influenza among travelers returning
from affected countries.
1) Recommend a flu vaccine as vigorously as you would any life-saving measure. This year, more
influenza vaccine will be available as compared to any previous year; total production is estimated to be
approximately 127-132 million doses. Four manufacturers currently supply inactivated influenza vaccine
to the United States market: sanofi Pasteur (Fluzone®), GlaxoSmithKline (Fluarix™ and FluLuval™),
Novartis (Fluvirin™), and CSL (Afluria®). A fifth manufacturer, MedImmune, manufactures a live,
attenuated intranasal vaccine (FluMist®). Influenza vaccine distribution began in September and is
expected to continue through January. Vaccine is still available for purchase. Providers in need of vaccine
should first check with their supplier. If unable to obtain vaccine, requests for vaccine can be placed
through DOHMH at www.nyc.gov/health/flu or by calling 1-866-NYC-DOH1. If you have questions
about your Vaccines for Children (VFC) flu vaccine order or need to order additional VFC vaccine,
please call 212-447-8175.
Changes in the influenza vaccination recommendations for the 2007-2008 influenza season include:
• Children aged 6 months to 8 years who received only 1 dose in their first year of influenza vaccination should receive 2 doses the following year. • Emphasis on importance of administering 2 doses of vaccine to all children aged 6 months to < 9 years if they have not been vaccinated previously at any time. • LAIV (FluMist®) may now be administered to persons aged 2-49 years. • Immunization providers should offer influenza vaccine and schedule immunization clinics • Healthcare administrators should consider the level of vaccination coverage among healthcare personnel to be one measure of a patient safety quality program and implement policies to encourage healthcare personnel vaccination.
DOHMH recommends that influenza vaccination proceed as soon as vaccine is received. There are
currently no restrictions on vaccine use. Vaccination should be given as soon as possible to provide
protection. Vaccination should continue until June as outbreaks have occurred in New York City as late
as May.
Influenza Vaccination for Healthcare Centers and Healthcare Personnel
Strategies to improve inpatient and outpatient influenza vaccination rates should be implemented. Use of
standing orders has been demonstrated to significantly increase coverage among patients and should be
considered the standard of care. New York State law requires that hospitals have standing order policies
in place for influenza and pneumococcal vaccination for all admitted persons age 65 and older. Increased
efforts should be undertaken to ensure that hospital and clinic staff are vaccinated; vaccination of staff has
been shown to decrease work absenteeism by approximately half. If employees decline influenza
vaccination, they should sign a refusal form acknowledging your commitment to staff vaccination. Go to
www.nfid.org/pdf/publications/hcwmonograph.pdf for information on strategies to promote influenza
vaccination among health care workers.
Additional information on influenza prevention and control and influenza vaccination recommendations
is available at www.nyc.gov/html/doh/downloads/pdf/chi/chi26-8.pdf. For more information about
standing orders, sample refusal forms, influenza and pneumococcal resource guide, posters and patient
education materials, and additional resources to promote influenza vaccination, go to
www.nyc.gov/health/flu or call the Bureau of Immunization at 212-676-2259.
2) Evidence of influenza activity in New York City so far this season
To date, three cases of culture-confirmed influenza have been reported. No institutional influenza
outbreaks have yet been reported, and the DOHMH’s syndromic surveillance systems have not yet shown
evidence of widespread influenza-like activity. As of early November 2007, there have been only a few
reports of laboratory-confirmed influenza A or B nationally, which is normal for this time of year.
3) Surveillance for pediatric influenza-associated deaths
A significant number of pediatric influenza-associated deaths occur among both children with underlying
medical conditions and in previously healthy children. More complete data are needed to better define the
burden of severe influenza in children and to develop appropriate strategies for prevention of pediatric
influenza-associated mortality. The CDC’s ACIP recommends that all children aged 6 to 59 months, and
contacts of children from birth to 59 months of age, receive annual influenza vaccination
(www.cdc.gov/mmwr/preview/mmwrhtml/rr5606a1.htm?s_cid=rr5606a1_e).
Suspected or confirmed influenza-associated death in a child less than 18 years of age is a reportable
condition in New York City. A suspected or confirmed influenza-associated death is defined as one either
resulting from a clinically compatible illness or confirmed to be influenza by an appropriate laboratory or
rapid diagnostic test. Laboratory testing for influenza A and B viral infection may be performed on pre- or
post-mortem clinical specimens. DOHMH can advise on appropriate laboratory testing and can facilitate
referral of specimens, including autopsy tissues, to reference laboratories. Providers should report any
case of suspected influenza-associated death occurring in a child less than 18 years of age to both the
DOHMH (see below) and the New York City Office of the Chief Medical Examiner at 212-447-2030 or
to a hospital pathologist for autopsy evaluation.

4) H5N1 influenza: International Surveillance Update and Reporting Criteria in NYC
The geographic spread of highly pathogenic avian (H5N1) influenza in wild and domesticated birds
continues in many parts of the world. Almost all human infections of avian influenza have resulted from
contact with infected poultry (i.e., chickens, ducks, or other domesticated birds), and human-to-human
transmission of avian influenza has been very limited to date. Until an avian influenza strain emerges that
can be transmitted efficiently from person to person, human H5N1 infection will not have demonstrated
pandemic potential.
Air travel can facilitate global spread of emerging infections, and NYC acute care and outpatient facilities
must remain alert for any recent traveler who presents with severe respiratory illness. To rapidly detect
the importation of influenza A (H5N1) into NYC, DOHMH requests that providers remain vigilant
for severe respiratory disease in travelers within 10 days of returning from countries with recently
confirmed H5N1 infections in poultry or humans. (See below for websites listing countries currently
affected by avian influenza.)

Interim Surveillance Criteria for Influenza A (H5N1): Febrile respiratory illness is one of the most
common indications for medical evaluation, especially during the winter season. Since human cases of
H5N1 influenza would be unlikely to occur in New York City in the absence of increased evidence of
human to human transmission in affected countries abroad, only suspect patients meeting the following
clinical and epidemiologic criteria should be reported to DOHMH:
• A patient who has an illness that requires hospitalization or is fatal; and has a documented
temperature of ≥38°C (≥100.4° F); and has radiographically confirmed pneumonia, acute
respiratory distress syndrome (ARDS), or other severe respiratory illness for which an
alternate diagnosis has not been established; and has at least one of the following potential
exposures within 10 days of symptom onset:
A. History of travel to a country with influenza H5N1 documented in poultry, wild birds, and/or humans, and had at least one of the following potential exposures during travel: ƒ Direct contact with (e.g., touching) sick or dead domestic poultry; ƒ Direct contact with surfaces contaminated with poultry feces; ƒ Consumption of raw or incompletely cooked poultry or poultry products; ƒ Direct contact with sick or dead wild birds suspected or confirmed to have ƒ Close contact (approach within 1 meter [approx. 3 feet]) of a person who was hospitalized or died due to a severe unexplained respiratory illness; B. Close contact (approach within 1 meter [approx. 3 feet]) of an ill patient who was confirmed C. Worked with live influenza H5N1 virus in a laboratory. • Testing for the following patients will be considered on a case by case basis:
• A patient with mild or atypical disease* (hospitalized or ambulatory) who has one of the exposures listed above (criteria A, B, or C); OR • A patient with severe or fatal respiratory disease whose epidemiological information is uncertain, unavailable, or otherwise suspicious but does not meet the criteria above (examples include: a returned traveler from an influenza H5N1-affected country whose exposures are unclear or suspicious, a person who had contact with well-appearing poultry, etc.) * For example, a patient with respiratory illness and fever who does not require hospitalization, or a patient with significant neurologic or gastrointestinal symptoms in the absence of respiratory disease.
Patients meeting these clinical and epidemiologic criteria should be placed in a separate room away from
other patients and cared for using standard, droplet, and airborne infection control precautions pending
further evaluation (see http://www.nyc.gov/html/doh/html/cd/cd-hcp-h5n1.shtml for specific details).
DOHMH should be notified as soon as possible and will provide further guidance on clinical
management, including arranging diagnostic testing and transportation of specimens to appropriate
reference laboratories. Diagnostic specimens (e.g., nasopharyngeal swabs or aspirates) should not be sent
for routine viral culture until H5N1 influenza is ruled out. These interim guidelines may change in the
future depending on updates in federal guidance or on changing epidemiologic features of avian influenza
in humans.
To ensure that individuals meeting the above criteria are rapidly identified, it is recommended that
acute and primary care facilities institute routine screening for travel history among all patients
with suspected pneumonia or severe respiratory infections at the time of triage or on initial medical
evaluation. Please note that the list of countries affected by H5N1 will likely change. Monitoring the
following websites is recommended for the most up-to-date information on current avian influenza
activity worldwide:
Centers for Disease Control and Prevention: http://www.who.int/csr/disease/avian_influenza/en/ REPORTING SUSPECTED FATAL PEDIATRIC INFLUENZA CASES OR
SUSPECTED CASES OF AVIAN INFLUENZA TO DOHMH:
¾ During business hours, call the Bureau of Communicable Disease at 212-788-9830.
¾ At all other times call the Poison Control Center at 212-764-7667 or 1-800-222-1222.

5) DOHMH does not recommend stockpiling of oseltamivir (Tamiflu®) or other influenza
antivirals: There is currently no sustained, efficient transmission of avian influenza viruses from person-
to-person occurring anywhere in the world. It is recommended that individuals NOT acquire or maintain
personal stockpiles of oseltamivir (Tamiflu®) or zanamivir (Relenza®). Providers should not provide
prescriptions to patients for this purpose since doing so might lead to a decrease in the available supply of
neuraminidase antivirals and might foster resistance to both human and avian influenza viruses if the
drugs were used improperly. In addition, it is unclear how persons with personal stockpiles would know
when to initiate therapy or what would constitute an effective regimen.
However, influenza antiviral medications (oseltamivir and zanamivir) should continue to be used for
prophylaxis and treatment of human influenza this season, especially in persons deemed at high risk for
serious complications secondary to influenza infection. During the past two influenza seasons, significant
influenza antiviral resistance was demonstrated against amantadine and rimantadine. Neither of these
drugs should be used currently for either prophylaxis or treatment of influenza because of concerns about
drug resistance.

As always, we appreciate the cooperation of the medical community in New York City and will update
you with further information when it becomes available.
Sincerely,

Source: http://www.nydis.org/nydis/nydisnet/2007/download/121207_SEND_Comm_DOHMHFluAdvisory112807.pdf