Each week CDC analyzes information about influenza disease activity in the United States and publishes findings of key flu indicators in a report called FluView. During the week of September 20-26, 2009, a review of the key indicators found that influenza activity remained elevated in the United States. Below is a summary of the most recent key indicators:
This algorithm is designed to assist physicians and those under their supervision in identifying indicators of and responses to symptoms of flu-like illness (i.e., fever with cough or sore throat). (NOTE: this guidance is not intended for use by the general public and is not a substitute for sound clinical judgment.)
Download and print the algorithm (PDF) >>
U.S. Situation Update
U.S. Patient Visits Reported for Influenza-like Illness (ILI)
U.S. Influenza-like Illness (ILI) Reported by Regions
U.S. Influenza and Pneumonia-Associated Hospitalizations | ||
Cases Defined by | Hospitalizations | Deaths |
Influenza and Pneumonia Syndrome* | 12,863 | 1,197 |
Influenza Laboratory-Tests** | 3,311 | 182 |
Totals: | 16,174 | 1,379 |
*Reports can be based on syndromic, admission or discharge data, or a combination of data elements that could include laboratory-confirmed and influenza-like illness hospitalizations. **Laboratory confirmation includes any positive influenza test (rapid influenza tests, RT-PCR, DFA, IFA, or culture), whether or not typing was done. This table is based on data from a new influenza and pneumonia hospitalizations and deaths web-based reporting system that will be used to monitor trends in activity. This is the third week of data from this new system. The table shows aggregate reports of all influenza and pneumonia-associated hospitalizations and deaths (including 2009 H1N1 and seasonal flu) since August 30, 2009 received by CDC from U.S. states and territories. This table will be updated weekly each Friday at 11 a.m. For the 2009-2010 influenza season, states are reporting based on new case definitions for hospitalizations and deaths effective August 30, 2009. CDC will continue to use its traditional surveillance systems to track the progress of the 2009-2010 influenza season. For more information about influenza surveillance, including reporting of influenza-associated hospitalizations and deaths, see Questions and Answers: Monitoring Influenza Activity, Including 2009 H1N1. The number of 2009 H1N1 hospitalizations and deaths reported to CDC from April – August 2009 is available on the Past Situation Updates page. For state level information, refer to state health departments. International Human Cases of 2009 H1N1 Flu Infection | ||
For more information about the U.S. situation, see the CDC H1N1 U.S. Situation Update page.
International Situation Update
This report provides an update to the international situation as of October 2, 2009. As of October 2, 2009, the World Health Organization (WHO) regions have reported over 343,298 laboratory-confirmed cases of 2009 H1N1 with at least 4,108 deaths, which is an increase of at least 24,373 cases and 191 deaths since September 20. The laboratory-confirmed cases represent a substantial underestimation of total cases in the world, as many countries focus surveillance and laboratory testing only on people with severe illness. The 2009 H1N1 influenza virus continues to be the dominant influenza virus in circulation in the world. From April 19 to September 19, 2009, 59.8% of influenza specimens reported to WHO were 2009 H1N1 viruses. In temperate regions of the Southern Hemisphere, disease due to 2009 H1N1 is declining or has returned to baseline. In tropical regions of the Americas and Asia, influenza activity due to 2009 H1N1 remains variable. In temperate regions of the Northern Hemisphere, there is increased influenza-like illness (ILI) activity due to 2009 H1N1 in many areas, including in most of the United States, parts of Mexico and Canada, some countries in Europe, and parts of Central and Western Asia.
For more information about the international situation, see the CDC H1N1 International Situation Update page.
Recent Updates of Interest
Additional Updates on the CDC H1N1 Flu Website
To learn about other recent updates made to the CDC H1N1 Flu Website, please check the "What's New" page on the CDC H1N1 Flu website.
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H1N1 UPDATE SEPTEMBER 14, 2009
FROM: NMDOH
SUBJECT: Updated Pediatric Antiviral Dosing Syringe and Compounding Information for 2009 H1N1 and Seasonal Flu
Detailed Message:
Pharmacists and physicians who care for pediatric patients should be aware of two issues: (1) the possible need to compound Tamiflu® on site if commercially manufactured pediatric oral suspension formulation is not available, and (2) the need to ensure that the units of measure on the dosing dispenser and the dosing instructions match.
Oseltamivir is authorized for emergency use in children younger than 1 year of age under an Emergency Use Authorization (EUA) issued by FDA. For the Emergency Use Authorization (EUA), see http://www.cdc.gov/h1n1flu/eua/pdf/tamiflu-hcp.pdf.
Early empiric treatment with oseltamivir or zanamivir should be considered for persons with suspected or confirmed influenza who are at higher risk for complications including:
Children 2 year to 4 years old are more likely to require hospitalization or urgent medical evaluation for influenza compared with older children, although the risk is much lower than for children younger than 2 years old. Children aged 2 years to 4 years without high risk conditions and with mild illness do not necessarily require antiviral treatment.
ALTERNATIVES TO TAMIFLU® ORAL SUSPENSION FOR PEDIATRIC PATIENTS
If pediatric formulations of Tamiflu® are not available, pharmacists may compound Tamiflu® 75 mg capsules into an oral suspension onsite. Compounding an oral suspension from Tamiflu® 75mg capsules provides an alternative when commercially manufactured oral suspension formulation is not readily available. Tamiflu® capsules may be compounded using the following vehicles:
Other supplies needed to compound include mortar and pestle and amber glass or amber polyethylene terephthalate (PET) bottle.
For the FDA -approved instructions for the emergency compounding of an oral suspension from
Tamiflu® 75mg capsules, see the FDA approved manufacturer package insert for oseltamivir
(Tamiflu®), available on the FDA Web site at http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM147992.pdf.
NOTE ON TAMIFLU® ORAL SUSPENSION SYRINGE
The second issue that pharmacists and physicians may face is the need to ensure that the units of measure on the dosing dispenser and the dosing instructions match. An oral dosing dispenser with 30 mg, 45 mg, and 60 mg graduations of Tamilfu® is provided in the packaging for the manufacturer's product rather than graduations in milliliters (mL) or teaspoons (tsp). This can lead to patient or caregiver confusion and dosing errors. When dispensing commercially manufactured Tamiflu® oral suspension, pharmacists should ensure the units of measure on the dosing instructions match the dosing device provided. If prescription instructions specify administration using mL or tsp, then the device included in the Tamiflu® product package should be removed and replaced with an appropriate measuring device, such as an oral syringe if the prescribed dose is in milliliters (mL).
For children younger than 1 year of age, the oral Tamiflu® dosing dispenser that is included in the product package SHOULD ALWAYS BE REMOVED. Pharmacists and health care providers should provide an oral syringe that is capable of accurately measuring the prescribed milliliter (mL) dose, and counsel the caregiver how to administer the prescribed dose.
FOR MORE PEDIATRIC ANTIVIRAL INFORMATION:
Antiviral administration issues are also addressed in the updated interim recommendationsissued by CDC on September 22, 2009 for the use of antivirals in the treatment and prevention of influenza which can be found at http://www.cdc.gov/H1N1flu/recommendations.htm and in the 2009-2010 Influenza Season: Information for Pharmacists available at http://www.cdc.gov/H1N1flu/pharmacist/pharmacist_info.htm.
Questions and Answers: Antiviral Drugs, 2009-2010 Flu Season: http://www.cdc.gov/h1n1flu/antiviral.htm.
For additional information, you can also call CDC's toll-free hotline, 800-CDC-INFO (800-232-4636) TTY: (888) 232-6348, which is available 24 hours a day, every day.
HOW DO I ACCESS THE STATE STOCKPILE OF ANTIVIRALS FOR MY PATIENT?
A list of hospitals and clinics that have received stockpile antivirals (NMDOH Antiviral Shipments Hospitals, NMDOH Antiviral Shipments Clinics) and the NMDOH Antiviral Form (and a sample form already filled out) can be found at: http://nmhealth.org/H1N1/forms.shtml. To help NMDOH monitor antiviral use, health care providers will be asked to report basic demographic information and identify a patient risk category for each antiviral course released from the stockpile. Clinicians who are not affiliated with a participating hospital or clinic can fill out a regular prescription form and a NMDOH Antiviral Form for the patient. Encourage a non-ill person to deliver the forms and pick up the antivirals at the local stockpile site on behalf of the patient. FOR SPECIFIC QUESTIONS ON OBTAINING ANTIVIRAL MEDICATIONS IN NEW MEXICO, PLEASE CALL: 1-877-869-9175.
WHAT ARE THE RECOMMENDED TREATMENT AND PROPHYLAXIS DOSAGES AND REGIMENS FOR ANTIVIRALS?
Antiviral treatment and prophylaxis recommendations from CDC can be found at:
http://www.cdc.gov/h1n1flu/recommendations.htm.
LINK FOR MORE Q&A FOR PHYSICIANS:
http://nmhealth.org/H1N1/provider/NMDOH_H1N1QA_Healthcare Professionals_18Sept2009.pdf.
H1N1 UPDATE SEPTEMBER 14, 2009
Below is the most recent update on HINI. Please contact the Provider Response team for more information.
Defying the expectations of experts, clinical trials are showing that the new H1N1 swine flu vaccine protects with only one dose instead of two, so the vaccine supplies now being made will go twice as far as had been predicted.
The CDC has published a comprehensive list of planning elements for vaccination programs for H1N1. This list can be found at: http://www.cdc.gov/H1N1flu/vaccination/statelocal/planning_checklist.htm
Comments from Dr. Jeanette Velarde, Lovelace Health Plan, Medical Director:
As NM may not have an adequate amount of H1N1 vaccine for their first tier of high risk patients, the NMDOH has modified the CDC recommendations to include the following:
While the overall severity of H1N1 has been similar to seasonal influenza, about half of those sick enough to be hospitalized have had either underlying medical illness or been pregnant. As several of our hospitals have high volume Obstetrical services, I have attached in full the relevant guidance document published by the CDC. This also should be part of the Division H1N1 task forces’ consideration:
Considerations Regarding Novel H1N1 Flu Virus in Obstetric Settings
July 6, 2009 5:30 PM ET
This document has been developed to provide guidance for prevention and management of novel H1N1 flu infection in inpatient and out-patient obstetric settings. Severe illnesses among pregnant woman and infants have been reported in this outbreak, although the epidemiology and spectrum of illness among pregnant woman and infants are not fully understood at this time and are under investigation. Prevention of infection with novel influenza A (H1N1) virus in pregnant women and infants is the highest priority message in this guidance. Healthy pregnant women should have access to prenatal care and labor and delivery services in settings where they can be separated from persons who are ill or potentially ill with novel H1N1 flu infection. In addition, a cautious approach to the management of neonates with ill mothers is recommended which includes isolation and close observation. Recommendations are interim, based on current knowledge of the novel H1N1 flu outbreak in the United States, and may be revised as more information becomes available.
Background
Human infections with novel influenza A (H1N1) (initially referred to as “swine flu” or novel H1N1 flu) were first identified in April of 2009. The epidemiology and clinical presentations of these infections are currently under investigation. Initial findings indicate that this virus causes a spectrum of illness that is similar to that caused by seasonal influenza viruses. While many infections with novel influenza A (H1N1) virus are relatively mild, some persons infected with this virus have had severe or even fatal infections. There are insufficient data available at this time to determine which groups of people are at higher risk for complications of novel H1N1 flu virus. However, over half of persons who have required hospitalization because of novel influenza A (H1N1) virus infection have had an underlying medical condition or have been pregnant. In addition, evidence from the previous pandemics of 1918-1919 and 1957-1958 and from seasonal influenza suggests that pregnant women are likely to be at increased risk of morbidity and mortality related to infection with this novel flu virus. The impact of novel H1N1 flu on the newborn is unknown, but based on previous experience, newborns are expected to be at increased risk of severe illness.
Over 4 million live births occur in the United States each year and approximately 99% of these births occur in hospital settings. In addition, pregnant women frequently present to healthcare settings for prenatal care. Therefore, guidance related to control of novel H1N1 flu infection in these obstetric healthcare settings is needed for facilities that provide care for pregnant women.
General Considerations
A key concept for obstetric settings is to keep healthy pregnant women, in both inpatient and outpatient settings, separated from persons who are ill or potentially ill.Facilities should have a mechanism to identify and segregate ill patients, visitors, and staff.
Prenatal care, labor, and delivery services should be provided to healthy pregnant women in settings where the risk of exposure to novel H1N1 flu has been minimized.
Healthy pregnant women and infants who have not been in close contact with persons with suspected, probable, or confirmed novel H1N1 flu can be managed in the usual way in compliance with established infection control guidance. They should not be subject to the special considerations noted below.
Pregnant Women Exposed to H1N1
Post exposure antiviral chemoprophylaxis can be considered for pregnant women who are close contacts of persons with suspected or laboratory confirmed novel influenza A (H1N1) virus infection. If chemoprophylaxis medications are being taken, exposed pregnant women can be managed in the usual way in compliance with established infection control guidance. Women who have symptoms of influenza-like-illness (defined as fever (temperature of 100°F [37.8°C] or greater) and a cough and/or a sore throat in the absence of a KNOWN cause other than influenza) should be treated as if they had influenza.
Pregnant Women With Confirmed, Probable, or Suspected H1N1 Illness
In general, guidance for control of novel H1N1 flu infection in obstetric settings is consistent with that in other healthcare settings but also includes special considerations for prevention of infection in the newborn. Infants are known to be at higher risk of severe illness from seasonal influenza virus infections. Based on this experience, infants are also considered to be at higher risk for severe illness from novel influenza A (H1N1) virus infection. Because very little is known about prevention of novel H1N1 flu infection in infants, these recommendations are intended to minimize the potential for exposure to novel influenza A (H1N1) viruses when an ill pregnant women delivers her baby.
Special considerations in obstetric settings when a pregnant woman has confirmed, probable or suspected novel H1N1 flu (adapted from recommendations for seasonal influenza: http://www.cdc.gov/flu/professionals/infectioncontrol/peri-post-settings.htm) include:
Newborns of Ill Mothers
Because the risk for transmission of novel H1N1 flu from mother to fetus is unknown, the newborn should be considered to be potentially infected if delivery occurs during the 2 days before through 7 days after illness onset in the mother. Infection control procedures developed for novel H1N1 flu should be used for the newborn throughout the hospital stay (http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm). The newborn should be closely monitored for signs and symptoms of influenza. If signs or symptoms develop, testing should be performed, infection control measures should be continued, and treatment with anti-influenza medications should be considered (http://www.cdc.gov/h1n1flu/childrentreatment.htm). Oseltamivir is approved for prevention of influenza in patients 1 year of age and older; however, an emergency use authorization (EUA) has been issued for oseltamivir for influenza treatment and prevention in patients less than 1 year of age (http://www.cdc.gov/h1n1flu/recommendations.htm#C).
Chemoprophylaxis of infants less than 3 months of age is not typically recommended, as there are very limited data available on the safety and effectiveness of chemoprophylaxis for infants less than 3 months. However, in situations which are judged to be critical, chemoprophylaxis with oseltamivir can be considered.
Infant Feeding
Breastfeeding should be protected and supported at all times because of the protection from respiratory infection that breast milk provides to the infant. The mother with influenza-like-illness should be encouraged and assisted to express her milk. During this time, the infant should be fed the mother’s expressed milk by another person who is well. Treatment or chemophrophylaxis with antiviral medications is not a contraindication to breastfeeding. For other information related to infant feeding, please see http://www.cdc.gov/h1n1flu/breastfeeding.htm.
Visitors
Limit visitors to mothers in isolation for novel influenza A (H1N1) virus infection to persons who are necessary for the patients’ emotional well-being and care (http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm).