Swine Flu: Guidance and Resources for Clinicians

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From Medscape Infectious Diseases

Swine Flu: Guidance and Resources for Clinicians
Susan B. Yox, RN, EdD Authors and Disclosures Published: 04/28/2009

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Swine influenza is a highly contagious respiratory disease of pigs caused by one of several swine influenza A viruses. Outbreaks are common in pigs year-round, but infection in humans historically is a result of close contact with infected animals. This current virus is a novel influenza A virus, more properly termed a new subtype of influenza A (H1N1) that was not previously detected in swine or

humans. More important is that this new strain appears to be spread by human-to-human transmission. It is likely that most people, particularly those who do not have regular contact with pigs, do not have any immunity to swine influenza viruses. Thus the concern is that if efficient human-to-human transmission is established, a pandemic is possible. Government and public health officials are monitoring this situation worldwide to assess the threat from swine flu and to provide guidance to healthcare professionals and the public. Because the situation is changing rapidly, it is important to check regularly for changes in recommendations as new information becomes available.
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This article is based on guidance and resources available from both the United States Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO); they have been summarized here with the objective of offering practicing clinicians a one-stop resource for clinical practice concerns related to swine flu.

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Simulation Suggests That Rapid Activation of Social Distancing Can Arrest Epidemic Development Due to a Novel Strain of Influenza Early Estimate of Pandemic Potential of Influenza A H1N1 "Swine Flu"

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What Is the Clinical Presentation of Swine Flu?

Persons infected with swine flu may appear similar to those with seasonal influenza, presenting with symptoms of acute respiratory illness. Symptoms include at least 2 of the following:

http://www.medscape.com/viewarticle/702050?src=emailthis (1 of 5)05-Aug-09 5:25:16 PM

a person with an acute respiratory illness who has a recent history of contact with an animal with confirmed swine influenza should also be suspected (http://www. Swabs with cotton tips and wooden shafts are not recommended. chills. and Fever. Sore throat. q q q In addition. In the past. swab specimens should be collected using swabs with a synthetic tip and an aluminum or plastic shaft. If swine flu is suspected. have presented in young adults. At this time. In an ideal situation. Illness-related fatalities have been recorded in Mexico. go to http://www. it is not clear why such differences in illness severity have been seen.com/viewarticle/702050?src=emailthis (2 of 5)05-Aug-09 5:25:16 PM .gov/swineflu/recommendations. Most of the recent cases seen in the United States thus far have been mild as well. (To find the most up-to-date information on areas with confirmed swine influenza cases. What Is the Range of Illness Severity Seen With Swine Flu? Many cases of swine flu may be mild or even asymptomatic. respiratory failure.gov/swineflu/index. however. in Mexico. How Should Swine Flu Be Diagnosed? Preferred specimens. and acute respiratory distress syndrome. In addition. and have included pneumonia.cdc. fatigue. clinicians should obtain a respiratory specimen for analysis. Cough. Early in epidemics it is difficult to gauge severity because the overall denominator of people infected is unknown. If these specimens cannot be collected. a combined nasal swab with an oropharyngeal swab is also acceptable and will be feasible in most settings.Swine Flu: Guidance and Resources for Clinicians q Rhinorrhea or nasal congestion. the best method is via nasal pharyngeal aspirate or nasal wash aspirate into viral culture media.medscape.cdc.) http://www. Who Is Most at Risk for Swine Flu? The CDC recommends that clinicians particularly consider the possibility of swine influenza A (H1N1) virus infection in patients with fevers and respiratory symptoms who: q Live in areas in the United States with confirmed human cases of swine influenza A (H1N1) virus infection.htm). (Ideally.htm) q Traveled recently to Mexico or were in contact with persons who had febrile respiratory illness and were in areas of the United States with confirmed swine influenza cases or Mexico in the 7 days preceding illness onset. some experts are recommending the use of Dacron nasal swabs to decrease aerosolization of the virus. persons with swine flu may have other typical symptoms of influenza. Specimens collected with swabs made of calcium alginate are not acceptable. cases were identified by chance as part of regular seasonal influenza surveillance. headache. many patients' illnesses have been much more severe. including body aches. However. and possibly diarrhea and vomiting.

negative rapid tests should not indicate a lack of influenza.g. It is resistant to amantadine and rimantadine (http://www. Other tests.gov/flu/professionals/diagnosis/rapidlab.gov/swineflu/recommendations. Pregnant women: Antiviral medications are in Pregnancy Category C. Recommended tests..cdc. see http://www. Rapid testing for swine flu likely is similar to that for seasonal flu. A negative viral culture does not exclude infection with swine influenza A (H1N1) virus. A patient with a positive rapid test for influenza A may meet criteria for a probable case of swine flu. so they should be used during pregnancy only if the q http://www. A patient who is positive for influenza A by immunofluorescence may meet criteria for a probable case of swine influenza. H3 conducted at a State Health Department Laboratory. a negative immunofluorescence could be a false negative and should not be assumed a final diagnostic test for swine influenza infection. Immunofluorescence (DFA or IFA) tests can distinguish between influenza A and B viruses. check regularly at: http://www. swine influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by realtime RT-PCR. Therefore. q Confirmed cases: Zanamivir or oseltamivir should be administered for 5 days. depending on the manufacturer.htm).htm) Rapid tests can distinguish between influenza A and B viruses. Currently.medscape. swine influenza A (H1N1) is susceptible to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir.gov/swineflu/specimencollection. a negative rapid test could be a false negative and should not be assumed a final diagnostic test for swine influenza infection. B. However.htm How Can Swine Flu Be Treated? According to the CDC. meaning that sensitivities range between 50% and 70% of cases (no better than using fever and cough as a marker in a patient during influenza season). (For general guidance on rapid influenza testing. If reactivity of real-time RT-PCR for influenza A is strong (e. make contact with the state or local health department to facilitate transport and timely diagnosis at a state public health laboratory. Once collected. Ct ≤ 30) it is more suggestive of a novel influenza A virus. Isolation of swine influenza A (H1N1) virus by viral culture is also diagnostic of infection but may not yield timely results for clinical management.com/viewarticle/702050?src=emailthis (3 of 5)05-Aug-09 5:25:16 PM . H1. To stay up-to-date on the latest recommendations for testing.Swine Flu: Guidance and Resources for Clinicians The specimen should be placed in a 4°C refrigerator (not a freezer) or immediately placed on ice or cold packs for transport to the laboratory." Confirmation as swine influenza A (H1N1) virus is now performed at the CDC but may be available in state public health laboratories soon. Rapid influenza testing.cdc. but again. The CDC currently recommends "real-time RT-PCR for influenza A.cdc. Treatment recommendations are as follows: q Suspected cases: Treat with zanamivir alone or with a combination of oseltamivir and either amantadine or rimantadine as soon as possible after the onset of symptoms and for a duration of 5 days.

2.cdc. elderly). Maryland.cdc. gov/swineflu/recommendations.cdc.cdc. MD. Household close contacts of a confirmed or suspected case who are at high risk for complications of influenza (persons with certain chronic medical conditions. MBA. q Children younger than 1 year: Because infants typically have high rates of morbidity and mortality from influenza. and contact precautions should be implemented and maintained by healthcare professionals for 7 days after the illness onset or until symptoms have resolved (http://www. elderly). The CDC recommends that the following populations receive chemoprophylaxis: 1. Vice President/Medical Director of Medscape and Editorin-Chief of eMedicine. MD. See http://www. 3. The patient should wear a mask when outside the room. Clinical Director in the Division of Infectious Diseases at Johns Hopkins University School of Medicine in Baltimore. Detailed guidance on antiviral treatment for swine flu may be found here: http://www. The author wishes to thank Paul G. and Rick Kulkarni. Standard.htm) For How Long Is Swine Flu Contagious? Persons with swine flu are considered infectious for 1 day before onset of the illness to 7 days after the onset.com/viewarticle/702050?src=emailthis (4 of 5)05-Aug-09 5:25:16 PM . infants with swine influenza A (H1N1) infections may benefit from treatment with oseltamivir. Border workers (Mexico) who are at high risk for complications of influenza (persons with certain chronic medical conditions.medscape. 4. School children who are at high risk for complications of influenza (persons with certain chronic medical conditions) who have had close contact (face-to-face) with a confirmed or suspected case. droplet.htm Should Antiviral Chemoprophylaxis Be Considered for Specific Populations? Chemoprophylaxis is recommended for 7 days after the last known exposure to a confirmed case of swine influenza A (H1N1) virus. Auwaerter.gov/swineflu/recommendations. What Infection-Control Precautions Should Be Taken in Healthcare Settings? Patients who have a suspected or confirmed case of swine flu and who need to be hospitalized should be placed in a single-patient room with the door kept closed. Travelers to Mexico who are at high risk for complications of influenza (persons with certain chronic medical conditions.htm#table for dosing and schedules.gov/swineflu/guidelines_infection_control. for review of this article.gov/flu/professionals/antivirals/dosagetable.Swine Flu: Guidance and Resources for Clinicians potential benefit outweighs the potential risk to the embryo or fetus. elderly). (Detailed guidance on this topic is available at http://www. 5. Healthcare workers or public health workers who have had unprotected close contact with a person with confirmed swine influenza A (H1N1) virus infection during the infectious period.htm). http://www.

or touch infected hands or surfaces. Like seasonal flu. swine flu may cause a worsening of underlying chronic medical conditions.com Home Headlines Opinion Features Buzz Hi Guest Sign In | Create a Rediffmail account Everything you need to know about swine flu Email this Save to My Page Ask Users Write a Comment Everything you need to know about swine flu Rediff News Bureau India is grappling with a swine flu epidemic. cough. Source: Ministry of Health Image: A mother puts on a surgical mask for her daughter as they arrive for a H1N1 flu screening at Ram Manohar Lohia hospital in New Delhi Photographs: Fayaz Kabli/Reuters Prev Next Prev Next http://news. Another person can breathe in contaminated air. sore throat and runny nose. headache. infected droplets get on their hands. and sometimes vomiting or diarrhoea. or are dispersed into the air. Here's an FAQ on the dreaded virus: How do people become infected with influenza A (H1N1)? Outbreaks in humans are now occurring from human-to-human transmission.com news rediff. including fever. and be exposed.htm (1 of 2)09-Aug-09 11:17:07 AM . muscle and joint pain. drop onto surfaces.rediff.Everything you need to know about swine flu: Rediff. What are the signs and symptoms of infection? Early signs of influenza A (H1N1) are flu-like. When infected people cough or sneeze. Is there any confirmation of transmission between pigs and humans at this point? No.There is heightened panic among people following reports of growing number of HIN1 cases and the recent death of a school child in Pune.com/slide-show/2009/aug/07/slide-show-1-faq-on-swine-flu.

rediff. or mouth. nose.Privacy Policy .Disclaimer .com Home Headlines Opinion Features Buzz Hi Guest Sign In | Create a Rediffmail account Everything you need to know about swine flu Email this Save to My Page Ask Users Write a Comment Everything you need to know about swine flu How soon can someone with the flu infect someone else? Infected people may be able to infect others beginning one day before symptoms develop and up to seven or more days after becoming sick.Advertise with us . 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. doorknobs.Feedback http://news. Image: A nurse carries masks and medicine outside the influenza A (H1N1) ward in Mumbai Photographs: Stringer/Reuters Prev Next Prev Next © 2009 Rediff.com news rediff.htm09-Aug-09 11:18:26 AM .Investor Information .Everything you need to know about swine flu: Rediff. How long can viruses live outside the body? We know that some viruses and bacteria can live two hours or longer on surfaces like cafeteria tables. Droplets from a cough or sneeze of an infected person move through the air.com/slide-show/2009/aug/07/slide-show-1-faq-on-swine-flu.com . Frequent hand washing will help you reduce the chance of getting contamination from these common surfaces. and desks.

Throw the tissue in the trash after you use it.com/slide-show/2009/aug/07/slide-show-1-faq-on-swine-flu. Image: Women wearing masks wait to receive medical attention for suspected H1N1 influenza at a hospital in Pune Photographs: Stringer/Reuters Prev Next © 2009 Rediff.Privacy Policy .Disclaimer . one must stay at home. nose or mouth. q Wash your hands often with soap and water.Everything you need to know about swine flu: Rediff. especially after you cough or sneeze.Investor Information . However. q Avoid touching your eyes.com Home Headlines Opinion Features Buzz Hi Guest Sign In | Create a Rediffmail account Everything you need to know about swine flu Email this Save to My Page Ask Users Write a Comment Everything you need to know about swine flu What can I do to protect myself from getting sick? Currently available seasonal influenza vaccine does not protect against H1N1 flu.rediff.Advertise with us . away from work or school and limit contact with others to keep from infecting them.com news rediff. if one is having any respiratory distress. Try to avoid close contact with people having respiratory illness.com .htm09-Aug-09 11:18:54 AM . Germs Prev Next q q spread this way. If one gets sick with influenza. Alcohol based hand cleaners are also effective. one should report to a nearby hospital. Take these everyday steps to protect your health: q Cover your nose and mouth with a tissue when you cough or sneeze.Feedback http://news. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza.

Advertise with us . be physically active. Image: People ride past a billboard carrying messages on prevention of the Influenza A (H1N1) virus in Hyderabad Photographs: Krishnendu Halder/Reuters Prev Next Prev Next © 2009 Rediff. drink plenty of fluids. Get plenty of sleep. If you get sick. They may also prevent serious flu complications. and eat nutritious food.com/slide-show/2009/aug/07/slide-show-1-faq-on-swine-flu.com news rediff. Try to stay in good general health.Feedback http://news. Oseltamivir is the recommended anti viral drug for the treatment and/or prevention of infection with the influenza A H1N1.Privacy Policy .Everything you need to know about swine flu: Rediff.Disclaimer . antiviral drugs work best if started soon after getting sick (within 2 days of symptoms). Are there medicines to treat swine flu? Yes.rediff.com .Investor Information . The government has adequate stock and the drug is made available to government hospitals at the time of outbreak and would be available to you free of cost. manage your stress. Avoid close contact with people having respiratory illness.com Home Headlines Opinion Features Buzz Hi Guest Sign In | Create a Rediffmail account Everything you need to know about swine flu Email this Save to My Page Ask Users Write a Comment Everything you need to know about swine flu What should I do to keep from getting the flu? First and most important: wash your hands frequently. The drug is to be administered under supervision of clinicians. Avoid touching surfaces that may be contaminated with the flu virus.htm09-Aug-09 11:19:24 AM . antiviral drugs can make your illness milder and make you feel better faster. For treatment.

htm09-Aug-09 11:19:49 AM . nausea.Disclaimer . Your health care provider will determine whether influenza testing or treatment is needed. fever. body aches.com/slide-show/2009/aug/07/slide-show-1-faq-on-swine-flu.Investor Information . If you become ill and experience any of the following warning signs.com news rediff.Privacy Policy .g.Everything you need to know about swine flu: Rediff. Image: Children hold placards while posing for the media as they take part in a Photographs: Krishnendu Halder/Reuters Prev Next Prev Next © 2009 Rediff. or vomiting or diarrhea.com .com Home Headlines Opinion Features Buzz Hi Guest Sign In | Create a Rediffmail account Everything you need to know about swine flu Email this Save to My Page Ask Users Write a Comment Everything you need to know about swine flu What should I do if I get sick? If you live in areas where influenza A H1N1 cases have been identified and become ill with influenza like symptoms e.Feedback http://news. runny nose. particularly if you are worried about your symptoms. you should stay home and avoid contact with other people as much as possible to keep from spreading your illness to others.rediff. sore throat. seek emergency medical care. If you are sick. you may contact their health care provider.Advertise with us .

emergency warning signs that need urgent medical attention include: q q q q q Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting Can I get influenza A H1N1 from eating or preparing pork? No.com Home Headlines Opinion Features Buzz Hi Guest Sign In | Create a Rediffmail account Everything you need to know about swine flu Email this Save to My Page Ask Users Write a Comment Everything you need to know about swine flu In children emergency warning signs that need urgent medical attention include: Fast breathing or trouble breathing Bluish skin color q Not drinking enough fluids/eating food q Not waking up or not interacting q Being so irritable that the child does not want to be held q Flu-like symptoms improve but then return with fever and worse cough q Fever with a rash q q Prev Next In adults.com/slide-show/2009/aug/07/slide-show-1-faq-on-swine-flu.com news rediff.Privacy Policy . swine influenza viruses are not spread by food.Investor Information .com .Feedback http://news.Advertise with us . Image: People wearing surgical masks walk out of a H1N1 flu screening centre in Ram Manohar Lohia hospital in New Delhi Photographs: Fayaz Kabli/Reuters Prev Next © 2009 Rediff.Disclaimer .rediff.htm (1 of 2)09-Aug-09 11:20:26 AM . Eating properly handled and cooked pork products is safe.Everything you need to know about swine flu: Rediff.

com news rediff.Feedback http://news.Advertise with us .Privacy Policy .com/slide-show/2009/aug/07/slide-show-1-faq-on-swine-flu.com .com Home Headlines Opinion Features Buzz Hi Guest Sign In | Create a Rediffmail account Everything you need to know about swine flu Email this Save to My Page Ask Users Write a Comment Everything you need to know about swine flu DOs: * Wash your hands * Avoid crowded places * Stay more than an arm's length from persons afflicted with flu * Get plenty of sleep * Drink plenty of water and eat nutritious food DO NOTs: * Shake hands or hug in greeting * Spit in public * Take medicines without consulting a physician For people who are sick: * Stay home and limit contacts with others as much as possible * Rest and take plenty of liquids * Cover your mouth and nose when you cough or sneeze * Seek medical advice if needed. Image: People wearing masks wait to get tested for H1N1 influenza at a special ward in Kasturba Hospital in Mumbai Photographs: Punit Paranjpe/Reuters More Prev Next Prev Next More © 2009 Rediff.Investor Information .htm09-Aug-09 11:20:51 AM .Disclaimer .Everything you need to know about swine flu: Rediff.rediff.

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