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Pandemic Influenza:Clinical and Public HealthGuidelines for theMilitary Health System
Swine-Origin Influenza A(H1N1) Virus in 2009
 
June 2009
 
 i
Table of Contents
 
Introduction .................................................................................................................................1I. Guidelines for Patient Evaluation and Management (E&M) ...................................................2A. Federal Government Response Stages 0-2 (WHO Phases 1-5)..........................................21. Evaluation of Patient with Influenza-like Illness (ILI).................................................2a. Epidemiologic Criteria............................................................................................2 b. Clinical Criteria.......................................................................................................3c. Screening Methods for Patients with Suspected Swine-origin Influenza A...........5d. Interpretation of Laboratory Test Results...............................................................52. Management of Patients with Suspected Pandemic Strain Influenza ..........................5a. Patient Placement and Transport............................................................................5 b. Hospitalization (Inpatient) .....................................................................................7c. Hospitalization (Intensive Care Unit)...................................................................17d. Outpatient/Home/Congregate Housing.................................................................17
e.
Post-mortem Care and Safe Autopsy Procedures for Novel H1N1 Influenza …..18B. Federal Government Response Stages 3-6 (WHO Phase 6).............................................181. Evaluation of Patients with ILI...................................................................................18a. Epidemiologic Criteria..........................................................................................18 b. Clinical Criteria.....................................................................................................182. Management of Patients with PI during Federal Government Response Stages 3-6..19a. Hospitalization (Inpatient)....................................................................................19 b. Hospitalization (Intensive Care Unit)...................................................................21c. Outpatient/Home/Congregate Housing.................................................................22II. Guidelines for Laboratory Planning and Diagnostics – 2009 H1N1 Flu................................23A. General Information..........................................................................................................231. Additional References.................................................................................................232. Surveillance and Diagnostic Testing Goals................................................................233. Laboratory Planning Guidance...................................................................................244. DoD Influenza Population-based Surveillance Programs ..........................................265. General Influenza Testing Guidance..........................................................................27a. Laboratory Management Personnel......................................................................27 b. DoD Medical Center/non-MTF Laboratories.......................................................30B. Testing Flow and Reporting Procedures...........................................................................301. Testing Flow – PI Virus Exposure Risk Factors Are Not Present..............................302. Testing Flow – PI Virus Exposure Risk Factors Are Present.....................................30a. Heightened vigilance for ILI patients at increased risk of infection with the2009 H1N1 or other novel influenza viruses........................................................31 b. Flow of testing for ILI patient with the 2009 H1N1) virus (S-OIV) or other novel influenza virus infection risk.......................................................................32c. Laboratory Actions...............................................................................................33d. After the Pandemic Virus has been Identified......................................................333. Reporting Procedures..................................................................................................33a. DoD Medical Center/non-MTF Laboratories.......................................................34
 
 iib. Referring Laboratory............................................................................................34C. Special Instructions – Autopsy Specimens and Shipping of Specimens .........................341. Autopsy Specimen Instructions..................................................................................342. General Specimen Shipment Instructions...................................................................35D. Guidelines for Collection of Clinical Specimens..............................................................361. Collecting Respiratory Specimens..............................................................................36a. General Information..............................................................................................36 b. Collecting Specimens from the Upper Respiratory Tract.....................................37c. Collecting Specimens from the Lower Respiratory Tract....................................382. Blood Components......................................................................................................38III. Occupational Health Guidelines for Health Care and Medical Research Personnel .............40A. Surveillance.......................................................................................................................40B. Influenza vaccine..............................................................................................................41C. Pre-exposure antiviral prophylaxis...................................................................................41D. Follow-up of Suspected Exposures...................................................................................41E. Post-exposure prophylaxis................................................................................................41F. Personal Protective Equipment.........................................................................................42G. Management of ILI in Health Care Personnel with Suspected Exposure to NovelInfluenza Viruses..............................................................................................................421. General Procedures......................................................................................................422. Evaluation and Management........................................................................................42a. During Regular Working Hours............................................................................42 b. During Working Hours when the Employee Calls from Home............................43c. After Working Hours............................................................................................43IV. Guidelines for Community Disease Containment.................................................................43A. Surveillance.......................................................................................................................43B. Targeted Layered Interventions .......................................................................................441. Transmission of S-OIV (H1N1)..................................................................................442. Timing.........................................................................................................................443. Closure of Schools, Child Care Centers, and Other Child-based Programs ..............454. Social Distancing .......................................................................................................465. Open Barracks ............................................................................................................466. Prompt Isolation .........................................................................................................477. Post-Exposure Prophylaxis ........................................................................................478. Graded Response .......................................................................................................489. Communication...........................................................................................................4810. Community Mask Use ...............................................................................................48V. Special Considerations for Deployed Settings .......................................................................49A. Guidelines for Patient E&M during Federal Government Response Stages 0-2(WHO Phases 1-5) ...........................................................................................................491. Evaluation and Management
 
of Patients with ILI and PI risk factors – Role I..........492. Evaluation and Management
 
of Patients with ILI and PI risk factors – Role II.........493. Evaluation and Management
 
of Patients with ILI and PI risk factors – Role III........50
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