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LOS ANGELES COUNTY ? DEPARTMENT OF PUBLIC HEALTH ACUTE COMMUNICABLE DISEASE CONTROL PROGRAM

October 31, 2013

TO: FROM: SUBJECT:

Area Health Officers Area Medical Directors Nurse Managers

Laurene Mascola, M.D., M.P.H., F.A.A.P. Chief, Acute Communicable Disease Control Program

RESPIRATORY OUTBREAK AND INFLUENZA B-73 ANNOUNCEMENT

The Acute Communicable Disease Control Program (ACDC) has recently updated two chapters to the Los Angeles County Department of Public Health Communicable Disease Control Manual (B-73): Respiratory Disease Outbreaks and Influenza. The following are highlights of changes and issues for closer consideration:

? All respiratory disease outbreaks should be initially reported as respiratory outbreaks (unknown) until laboratory testing confirms the etiology. The initial forms for beginning the investigation are the same as those used for reporting influenza outbreaks.

? Because we know influenza outbreaks are underreported, and to encourage staff to obtain nasopharyngeal (NP) specimens for confirmation, a respiratory outbreak can be classified as an influenza outbreak with one laboratory confirmed case of influenza.

? A cluster or outbreak in a congregate-living facility (e.g., jail, juvenile hall, camps, assisted living centers) is defined as three or more cases of suspected influenza occurring within 48 to 72 hours in residents who are in close proximity to each other (i.e., in the same area of the facility).

? A cluster or outbreak in schools and daycare centers (i.e., community-based) is defined as a sudden increase of influenza cases over the normal background rate or 5 or more cases of suspected influenza in one week in an epidemiologically linked group (such as a sports team, single classroom, after school group).

? One case of confirmed influenza by any testing method in a skilled nursing facility resident is to be considered an outbreak (until proven otherwise) and should prompt enhanced infection control and surveillance for other cases.

? Since 2010 in Los Angeles County (LAC), confirmed influenza fatalities of any age are reportable. There are two new forms for the reporting of fatal influenza cases. For pediatric fatalities: InfluenzaAssociated Pediatric Mortality Case Report (CDC 8/13/2014). And for adults: (18 years and older) Influenza Fatality Case Report Form (acd-influ 9/13).

Because we are already receiving reports of influenza cases and respiratory outbreaks, it is critical that you review these new guidelines with your staff and ensure their understanding and preparedness as soon as possible. Our last influenza season in LAC was fairly severe with 50 reported community outbreaks illustrating that respiratory diseases can produce a serious impact even during non-pandemic years. Educational materials to encourage vaccination, effective respiratory hygiene and to inform the public about influenza are available on our website at:

For further questions regarding reporting and investigating respiratory disease outbreaks, please contact Wendy Manuel, M.P.H., Epidemiology Analyst of ACDC at (213) 240-7941.

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M:\Letters\2013\B73-SR-014.docx

Attachments

c: Wendy Manuel, M.P.H. Sadina Reynaldo, Ph.D.

Attachment 1

Acute Communicable Disease Control Manual (B-73) REVISION--OCTOBER 2013

INFLUENZA (Select Individual Cases and Outbreaks)

(also see Respiratory Disease Outbreaks)

Note: Suspected influenza outbreaks should be initially reported as respiratory outbreaks (unknown) until laboratory testing confirms influenza as the etiology.

1. Agent: Influenza viruses. Only influenza A and B are of public health concern since they are responsible for epidemics.

2. Identification:

a. Symptoms: New acute onset of fever >100?F (38?C), non-productive cough, sore throat, chills, headache, myalgia, and malaise. Can sometimes also cause gastrointestinal (GI) symptoms. Duration is 2-4 days in uncomplicated cases, with recovery usually in 5-7 days. Infection with non-human strains of influenza such as avian influenza viruses theoretically may cause other illness, such as conjunctivitis, gastroenteritis or hepatitis.

b. Differential Diagnosis: Other agents that cause febrile respiratory illnesses or community acquired pneumonia including, but not limited to Mycoplasma pneumoniae, adenovirus, respiratory syncytial virus, rhinovirus, parainfluenza viruses, Legionella spp, and coronavirus.

c. Diagnosis: Confirmed by viral isolation, PCR, rapid antigen test, or a DFA/IFA test, and compatible symptoms.

3. Incubation: 1-4 days; average 2 days.

4. Reservoir: Humans, swine, and migratory birds.

5. Source: Mostly droplet spread by nasal or pharyngeal secretions and sometimes fomites.

6. Transmission: Large droplet spread from infective persons or sometimes contaminated fomites. Airborne spread possible, but unlikely.

7. Communicability: People infected with flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days

after. This can be longer in some people, particularly and people with weakened immune systems

8. Specific Treatment: Supportive care (e.g., rest, antipyretics, fluids, etc.). Antiviral medications may reduce the severity and duration of influenza illness if administered within 48 hours of onset. These same medications may be useful for hospitalized patients or those who are immunocompromised or if vaccine does not cover circulating strain.

Streptococcal

and

staphylococcal

pneumonias are the most common

secondary complications and should be

treated with appropriate antibiotics.

9. Immunity: Permanent for a specific strain.

REPORTING PROCEDURES

1. Outbreaks reportable:

Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable.

Note: Suspected influenza outbreaks should be initially reported as respiratory outbreaks (unknown) until laboratory testing confirms influenza as the etiology.

A cluster or outbreak in a congregate-living facility (e.g., jail, juvenile hall, camps, assisted living centers) is defined as three or more cases of suspected influenza occurring within 48 to 72 hours in residents who are in close proximity to each other (i.e., in the same area of the facility).

A cluster or outbreak in schools and daycare centers (i.e., community-based) is defined as a sudden increase of influenza cases over the normal background rate or 5 or more cases of suspected influenza in one week in an epidemiologically linked group (such as a sports team, single classroom, after school group).

PART IV: Acute Communicable Diseases INFLUENZA -- page 1

Special Situations: One case of confirmed influenza by any testing method in a skilled nursing facility resident is to be considered an outbreak (until proven otherwise) and should prompt enhanced surveillance for other cases.

2. Single cases reportable.

a. Under Title 17, Section 2500, California Code of Regulations, all cases due to "novel" influenza A (for example due to avian or swine influenza) are reportable.

b. In Los Angeles County, influenza associated deaths at any age are reportable. Influenza-associated deaths must have had: 1) confirmed influenza by laboratory testing; and 2) a clinical syndrome consistent with influenza or complications of influenza (pneumonia, ARDS, apnea, cardio-pulmonary arrest, myocarditis, Reye syndrome or acute CNS symptoms (e.g., seizures, encephalitis). These Los Angeles County specific reporting requirements may change as circumstances change.

3. Report Forms: SEE TABLE 1

a. Use the following forms for outbreaks at various settings:

i. Non-healthcare facility For initial report of influenza outbreaks:

INITIAL ASSESSMENT OF RESPIRATORY OUTBREAK REPORT

For final report of an influenza outbreak (if outbreak continues after initial report has been filed):

Sample Line List-Non-Healthcare Facility for Students, Staff or Residents

FINAL ACUTE FEBRILE RESPIRATORY ILLNESS OUTBREAK REPORT FORM (CDPH 9003 3/12)

ii. Sub-acute healthcare facility For initial and final reports of influenza outbreaks:

Acute Communicable Disease Control Manual (B-73) REVISION--OCTOBER 2013

CD OUTBREAK INVESTIGATION --

SUB-ACUTE

HEALTH

CARE

FACILITY (H-1164-SubAcute, fillable)

For final report of a respiratory outbreak (if outbreak continues after initial report has been filed):

Sample Line List - Respiratory Outbreak Line List for Residents and Staff

FINAL

ACUTE

FEBRILE

RESPIRATORY ILLNESS OUTBREAK

REPORT FORM (CDPH 9003 3/12)

b. Use the following forms to report single cases of fatal influenza:

For pediatric fatalities:

INFLUENZA-ASSOCIATED PEDIATRIC MORTALITY CASE REPORT (CDC 8/13/2014)

For adults (18 years and older):

INFLUENZA FATALITY CASE REPORT FORM (acdc-influ 9/13)

4. Epidemiologic Data for Outbreaks:

a. Establish a case definition (i.e., fever [measured or reported] and either cough, sore throat, or stuffy nose): include pertinent clinical symptoms and laboratory data (if appropriate).

b. Confirm etiology of outbreak using laboratory data (rapid test, culture, or PCR). At least 1 patient must have tested positive for influenza in an outbreak to call it an "influenza" outbreak. Otherwise call it a "respiratory outbreak of unknown origin."

c. Create a line list that could include: i. names of cases ii. dates of onset iii. symptoms

iv. age v. hospitalization status vi. results of laboratory tests vii. prior immunization history viii. travel history, if relevant

PART IV: Acute Communicable Diseases INFLUENZA -- page 2

ix. epi links to other cases (room #s, grades in school, etc)

x. avian or swine exposure, if relevant

d. Create an epi-curve, by date of onset. Only put those that meet the case definition on the epi-curve.

e. Maintain surveillance for new cases until rate of influenza is down to "normal" or no new cases for 1 week.

f. Note: At least 1 patient must have tested positive for influenza in an outbreak to call it an "influenza" outbreak. Otherwise call it a "respiratory outbreak of unknown origin."

CONTROL OF CASE, CONTACTS & CARRIERS

CASE:

Precautions: None. Advise patients to stay away from work, schools, camps, and mass gatherings for at least 24 hours after resolution of fever. Limit exposure to others, especially those at high risk for complications.

Advise cases who work in health care settings not to return to work until 7 days after symptom onset or 24 hours after resolution of symptoms, whichever is longer.

As of 2010, there are two FDA approved drugs for the prevention and treatment of influenza A and B: oseltamivir (Tamiflu?) and zanamivir (Relenza?). Possible antiviral resistance should be considered before prescribing antivirals.

To follow current recommendations for treatment and prevention of influenza or for additional information about the use of antivirals for treatment and prophylaxis see:

CONTACTS: No restrictions. Prophylaxis with appropriate antiviral medication during outbreaks is advised for high-risk patients who have not been vaccinated or when the vaccine is of questionable efficacy.

CARRIERS: Not applicable.

Acute Communicable Disease Control Manual (B-73) REVISION--OCTOBER 2013

GENERAL CONTROL RECOMMENDATIONS FOR OUTBREAKS

1. Reinforce good hand hygiene among all

(including

visitors,

staff,

and

residents/students).

2. Emphasize respiratory etiquette (cover

cough and sneezes, dispose of tissues

properly).

3. Reinforce staying home when sick.

4. Provide posters and health education about

hand hygiene and respiratory etiquette.

5. Discourage sharing water bottles.

6. Emphasize importance of early detection of

cases and removing them from contact with

others.

7. Encourage standard environmental cleaning

with EPA registered disinfectant appropriate

for influenza viruses.

8. Consider isolation and/or cohorting and/or

quarantine for congregate-living facilities.

9. Consider canceling group activities.

10. Consider using influenza vaccine to control

situation (consult with ACDC).

11. Consider post-exposure prophylaxis with

antiviral medications for high-risk contacts

(consult with ACDC).

12. Provide educational materials to facility-

including posters, handouts, etc. Go to this

website to order influenza and respiratory

virus health education:



dFlu.htm

Note: The decision on what antiviral to use needs to be made on a case by case basis, depending on the strain of influenza causing the outbreak.

Consider the additional recommendations for congregate-living facilities, especially with high risk patients:

1. Close facility or affected areas to new admissions until 1 week after last case.

2. Suspend group activities until 1 week after last case.

3. If possible, separate staff that cares for sick from staff that cares for well patients.

4. Institute droplet precautions for symptomatic patients.

5. Refer to California Department of Public Health, Recommendations for the

PART IV: Acute Communicable Diseases INFLUENZA -- page 3

Prevention and Control of Influenza in California Long-Term Care Facilities. 6. Strongly consider using antiviral postexposure prophylaxis or vaccine to control outbreak (consult with ACDC or AMD).

Note: The decision on what antiviral to use needs to be made on a case by case basis, depending on the strain of influenza causing the outbreak.

DIAGNOSTIC PROCEDURES

Clinical and epidemiologic histories are required to aid in laboratory test selection.

Nasopharyngeal (NP) or nasal swab, and nasal wash or aspirate. PHL recommends Dacron or Nylon flocked swabs, do NOT use wooden swabs. NP swabs are preferred because the specimens can be tested for influenza and a variety of other respiratory pathogens using PCR based technology. All other specimens can only be tested for influenza. Samples should be collected within the first 4 days of illness. Collect specimens from at least 2 separate symptomatic individuals and up to 5 symptomatic individuals for any communitybased outbreak and select those individuals with the most recent onset for specimen collection.

1. Diagnostic tests available for influenza include viral culture, serology, rapid antigen testing, polymerase chain reaction (PCR), and immunofluorescence assays

2. NOTE: Culture should not be attempted when avian influenza is suspected. Contact Public Health Laboratory (PHL) or ACDC for instructions.

Container: Viral Culturette with M4 viral transport medium.

Laboratory Form: Reference Examination for Influenza A, B and/or Other Respiratory Viruses or online request if electronically linked to the PHL.

Examination: Testing algorithm is determined by the PHL.

Acute Communicable Disease Control Manual (B-73) REVISION--OCTOBER 2013

Material: Nasopharyngeal swab preferred; nasal swab can be used if necessary. See

And: Los Angeles County Department of Public Health Standardized Nursing Procedures: NP Competency Checklist (5/6/2009).

Storage: Keep refrigerated and upright. Deliver to PHL as soon as possible.

PREVENTION/EDUCATION

1. All persons >6 months are recommended to receive an annual influenza vaccine.

2. Practice good personal hygiene, avoid symptomatic persons during outbreaks, and do not go to work or school when ill with a respiratory disease.

3. Do not give aspirin to children with influenza and other viral illnesses.

4. Postpone elective hospital admissions during epidemic periods, as beds may be needed for the ill.

5. Sick visitors and staff should not be allowed in the facility.

ADDITIONAL RESOURCES

Additional information on the control of influenza during outbreaks, especially in healthcare facilities:

CDC. Infection Control for the Prevention and Control of Influenza in Health Care Facilities.

California Department of Public Health. Recommendations for the Prevention and Control of Influenza in California Long-Term Care Facilities.

Hospital Association of Southern California. Recommended Management Actions to Prepare Hospitals for Overflow Situations 2006-2007 Winter Season

LAC. Acute Communicable Disease Control Program.

PART IV: Acute Communicable Diseases INFLUENZA -- page 4

Seasonal Influenza in Adults and Children-- Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America. Clinical Infectious Diseases 2009; 48:1003?32.

______________________________________

AVIAN INFLUENZA

Avian flu refers to the disease caused by infection with avian (bird) influenza (flu) Type A viruses. These viruses occur naturally among wild aquatic birds worldwide and can infect domestic poultry and other bird and animal species. Avian flu viruses do not normally infect humans. However, sporadic human infections with avian flu viruses, including H5N1 and H7N9, have occurred.

For more information about avian influenza, visit:

______________________________________

SWINE INFLUENZA

Swine flu refers to the disease caused by infection with swine (pig) influenza (flu) Type A viruses. These viruses occur naturally among domesticated swine. Swine flu viruses do not normally infect humans but secondary human infections may occur from time to time. When it occurs, the strain of influenza is called "variant" to identify that it is not a "normal" human virus. However pigs can be infected with swine, avian, and human viruses at the same time. When this occurs, genes may be swapped between the different types of viruses resulting in the development of a new viral strain that is easily transmitted between humans. This occurred in 2009 with the development of the 2009 pandemic H1N1.

For more information about swine influenza see

Acute Communicable Disease Control Manual (B-73) REVISION--OCTOBER 2013

PART IV: Acute Communicable Diseases INFLUENZA -- page 5

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