Volume 15 / Issue 2 (November 2018)
Influenza Activity Remains Low in Orange County. Get Everyone Vaccinated Now Before It Increases!
Current Local Situation:  As of week 45 (ending 11/10/2018), overall influenza activity remains low throughout the county. No severe (defined as cases under the age of 65 years admitted to the intensive care unit or reported as a death) influenza cases have been reported so far this season.

Current State Situation:  As of week 45 (ending 11/10/2018), influenza activity is at low levels. The most frequently identified influenza virus type reported by Clinical Sentinel Laboratories was influenza A(H1N1)pdm09 virus.
Timing benefits for administering oseltamivir for treatment of severe influenza infection:  A study presented at the 2018 American College of Chest Physicians conference examined the clinical benefits of administering oseltamivir early on in severe influenza infection. Laboratory-confirmed influenza cases with acute respiratory distress syndrome (ARDS) treated with oseltamivir within 6 hours of triage had reduced length of hospital stay and a lower mortality rate. Shorter hospital stays may also reduce healthcare acquired infections. Original article posted in CHEST Journal here .

First new influenza antiviral approved in nearly 20 years:  The Food and Drug Administration has approved baloxavir marboxil (Xofluza) for the treatment of influenza in persons 12 years and older who have been symptomatic for no more than 48 hours. Clinical trial data demonstrated a single dose of baloxavir significantly reduced the median duration of influenza symptoms by about one day when compared to placebo, an effect similar to that of oseltamivir (Tamiflu) in another study. However, baloxavir was associated with greater reductions in viral load in the nose and throat by day 1 compared to oseltamivir. Original article published in New England Journal of Medicine here .

REMINDER: There are several FDA-approved antiviral drugs to treat influenza, but they are NOT a substitute for yearly vaccination.
Influenza Outbreak Recommendations for Long Term Care Facilities (LTCF)

Influenza can be introduced to a LTCF by newly admitted residents, health care workers and/or visitors, resulting in spread among the facility and severe, potentially fatal illness in this high risk population. Preventing transmission of influenza in LTCF, including SNF, involves a multi-faceted approach that starts with annual flu vaccination and development of an outbreak management plan. For detailed recommendations, see:
Before an Influenza Outbreak (Planning)
  1. Educate residents, healthcare personnel (HCP), and family members/visitors about influenza and its prevention.
  2. Vaccinate all residents and HCP annually against influenza before the beginning of influenza season and continue to vaccinate throughout the season.
  3. Develop/update influenza management plans, including but not limited to influenza vaccination and tracking, tracking of pneumococcal vaccination, implementation of daily active surveillance for influenza-like illness (ILI) during influenza season, process for influenza testing of residents, implementation of influenza infection control precautions (including respiratory hygiene / cough etiquette), outbreak management plan (see Outbreak box), process for obtaining and using antiviral agents for treatment and prophylaxis, and evaluation of lessons learned after influenza season.
Identifying and Managing Influenza Outbreaks
  1. Perform active surveillance for respiratory illness in residents and HCP.
  2. Test residents with suspected influenza. Molecular assays (such as reverse transcriptase polymerase chain reaction [RT-PCR]) are preferred. Immunofluorescence assays (DFA/IFA) and rapid influenza diagnostic tests are less sensitive and specific.
  3. Establish presence of an outbreak. An outbreak is defined as at least two (2) residents with onset of ILI within 72 hours of each other AND at least one (1) resident with laboratory confirmed influenza. Report any suspect and confirmed outbreaks to Orange County Public Health at 714-834-8180.
  4. Notify facility administration, HCP, residents/family/visitors as per outbreak plan, as well as CDPH Licensing & Certification, and Orange County Public Health as above. Post signs at facility entrances.
  5. Implement Droplet Precautions for residents with suspected or confirmed influenza. Emphasize respiratory hygiene/cough etiquette throughout facility.
  6. Treat all residents with confirmed or suspected influenza with CDC recommended antivirals as soon as possible after onset. Do NOT wait for confirmatory tests to initiate treatment. See https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm#dosage for more information. 
  7. Administer antiviral chemoprophylaxis to all non-ill residents in the facility, regardless of vaccination status, as soon as presence of outbreak established. Antiviral chemoprophylaxis should continue for a minimum of two weeks and for at least 7 days after the last known case is identified, whichever is longer.
  8. Define process for accepting and transferring patients; keeping ill residents separate from asymptomatic or new patients. Orange County Public Health will assist with determination if facility or unit should be closed to new admissions and duration of restrictions.
  9. Manage visitors, including education, screening, and encouraging vaccination and respiratory hygiene/cough etiquette.
  10. Review vaccination records for influenza and pneumococcus and vaccinate accordingly.
  11. Determine end of outbreak when no new cases have been identified for at least one (1) week after last case.
  12. Evaluate outbreak control measures and determine lessons learned for future outbreaks/seasons.
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