Update: April 28, 2009 Clinician Fact Sheet: Swine Influenza

Eight additional confirmed cases of swine influenza A (H1N1) continue to be identified in California, Kansas, Ohio, New York City and Texas. Arizona has not identified a case of swine influenza but continues to see seasonal influenza A cases. The following is interim guidance for clinicians.

Clinical Presentation of Initial U.S. Swine Flu Cases
·        Symptoms alone cannot distinguish swine flu from seasonal flu. Among reported US patients, illness has not been more severe than seasonal influenza.

Clinician Testing for Swine Flu
·        Clinicians should consider swine influenza infection in the differential diagnosis of patients with influenza-like illness (ILI), defined as fever [>100°F (37.8°C)] and cough and/or sore throat in the absence of a known cause. Patients who meet these criteria should be tested for influenza.
·        Clinician labs should conduct rapid test screening for influenza A. It is NOT necessary to use BSL-2 safety precautions as previously reported to perform screening testing, however standard droplet and contact precautions should be used (surgical mask, gown, gloves, and eye protection). All viral culturing must be performed using BSL-2 conditions.

If a patient tests positive for influenza A,
o       Send the specimen to the clinician's usual laboratory for culture and further testing.
o       If you do not have a usual laboratory, refrigerate the specimen and contact your local (county) health department to facilitate submitting specimens to the Arizona State Public Health Laboratory (ASPHL).
o       ASPHL will be open to receive flu samples 7 days / week from 8:00am through 5:00pm

Nasopharyngeal swabs (polyester) or nasal washes for influenza should be submitted in a universal viral transport medium (e.g. Hanks medium). Please indicate if the patient had a travel history in the seven days prior to onset.

Infection Control for Health Care Workers (HCWs)
·        HCWs should use standard and droplet precautions (including surgical mask and eye protection) at a minimum for influenza-like illnesses. In addition, CDC currently recommends contact precautions (gown and gloves). Standard precautions include good hand washing before & after patient contact.
·        HCWs caring for patients with laboratory-confirmed swine influenza or ill contacts of lab-confirmed cases should use N95 masks, eye protection (face shield or goggles), and disposable gloves and gown.
·        Swine flu patients and ill contacts of known swine flu patients should be placed in an airborne infection isolation room (AIIR), where possible, or a private room with the door closed.
·        Ill patients should wear a surgical mask when outside the patient room, if possible.
·        See detailed interim infection control recommendations at the following link: http://www.cdc.gov/swineflu/guidelines_infection_control.htm

Treatment & Prophylaxis
·        The U.S. swine influenza isolates are sensitive to oseltamivir and zanamivir, and resistant to amantadine and rimantadine, so use current influenza antiviral treatment recommendations for empiric therapy of patients with influenza-like illnesses (found at the following links) http://www.cdc.gov/flu/professionals/antivirals/index.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr54e713a1.htm
·        For empiric treatment of influenza-like illness:
o       Use of zanamivir for treatment or
o       Use dual therapy with both oseltamivir and rimantadine (or amantadine)
o       Only treat patients for suspected swine influenza if you would normally treat them for seasonal influenza.

·        Treat patients with confirmed swine influenza with either oseltamivir OR zanamivir
·        For information on chemoprophylaxis, please refer to www.cdc.gov/swineflu/recommendations.htm
·        Patients with influenza-like illness should be instructed to stay out of school or work for 7 days OR at least 24 hours after symptoms resolve.

Resources - continue to check for updates at
CDC Swine Influenza Site: http://www.cdc.gov/swineflu
·        ADHS Swine Influenza Site: http://www.azdhs.gov
ADHS Clinician Fact Sheet: Swine Influenza, Updated April 28, 2009