New Hampshire Health Alert Network: Oseltamivir Resistance H1N1 and Review of Clinical Guidance

New Hampshire Health Alert Network
Health.Alert@nh.gov

Status: Actual
Message Type: Alert
Severity: Moderate
Sensitive: Not Sensitive
Message Identifier: NH-HAN #20090715 Oseltamivir Resistance H1N1 and Review of Clinical Guidance
Delivery Time: 12 hours
Acknowledgement: No
Originating Agency: NH Department of Health and Human Services, Division of Public Health Services

DATE: July 15, 2009 TIME: 3:00 PM EDT
TO: Infection Control Practitioners, Infectious Disease Specialists, Physicians, NHHA, Hospital Emergency Departments, Community Health Centers, Influenza Sentinels, NH Schools, Manchester Health Department, EMS, Community Mental Health Centers, Nashua Health Department, DHHS Outbreak Team, Laboratory Response Network
FROM: José T. Montero, MD, Director of the NH Division of Public Health Services
SUBJECT: CDC Reports of Oseltamivir Resistant Novel Influenza A (H1N1) Viruses and Review of NH Clinical Guidance

NH Department of Health and Human Services (NH DHHS) recommends:
• Awareness of reported cases of oseltamivir resistant novel H1N1 virus infection and review of
the attached CDC Health Advisory.
• Judicious use of antiviral medications to reduce potential development and spread of antiviral resistant influenza viruses in accordance with CDC recommendations.
• Awareness of the recommendations for testing and use of the revised laboratory requisition form
• Encourage consistent use of respiratory hygiene and cough etiquette measures to prevent the spread of influenza. These routine preventive actions include frequent hand washing, covering coughs and sneezes and staying home when sick to keep from spreading illness.
• Remain alert to the occurrence of novel H1N1 influenza and influenza-like illness in NH through weekly flu surveillance reports and web updates.

Background:
NH DHHS continues to monitor the occurrence of novel H1N1 influenza and influenza-like illness through several surveillance systems. We expect that our ongoing surveillance for influenza will continue to detect novel H1N1 along with other circulating strains of influenza virus through the summer.
Although very few people in NH need to be tested, NH DHHS has confirmed a total of 232 cases as of July 6th. Recent activity includes clusters of influenza-like illness in summer camps.
NH DHHS recommendations for testing have not changed. Testing for novel H1N1 and seasonal influenza, including rapid tests, should be limited to the patients listed below. Regardless of rapid test results, patients in the categories below should be tested for novel H1N1 influenza through NH Public Health Laboratories.
1. Hospitalized patients with acute febrile respiratory illness or sepsis-like syndrome.
2. Health care workers with influenza-like illness in direct care patient settings in consultation with their health care provider.
3. Patients suspected to be part of a cluster of undiagnosed respiratory illness only in consultation with public health professionals (603-271-4496 or toll free at 800-852-3345, ext. 4496).
If you have a case that meets the above criteria please indicate the appropriate category on the lab requisition form. Samples sent to the NH Public Health Laboratories that do not indicate the above criteria will not be tested. (If you do not have the most current form, please write in the correct category
for your patient.)

Recommendations by CDC and NH DHHS for the use of antivirals have not changed and key points are highlighted below:
1. Most people who are infected with novel influenza A (H1N1) virus have had a self limited illness and have recovered without the need for antiviral medications.
2. Inappropriate use of oseltamivir for chemoprophylaxis could contribute to the development of oseltamivir resistance among novel influenza A (H1N1) viruses and the circulation of resistant viruses in the community.
3. Antiviral agents are discouraged for prevention of illness in healthy children or adults based on potential exposures in the community, school, camp or other settings.
4. The use of antiviral agents for treatment should be prioritized; zanamivir or oseltamivir are recommended for the treatment of persons with suspected novel H1N1influenza who are
a) Hospitalized.
b) At higher risk for complications due to influenza, even if hospitalization is not required.
5. Use of antiviral agents for chemoprophylaxis can be considered for
a) Close contacts of cases of ILI that are suspected or confirmed to be novel influenza
H1N1 who are at higher risk from complications due to influenza.
b) Healthcare workers who have had recognized unprotected close contact exposure* to a person with ILI that is suspected or confirmed to be novel influenza H1N1 during that person’s infectious period.

Recommendations by NH DHHS for decreasing transmission have not changed and key points are highlighted below:
1. All individuals (including healthcare workers) with influenza-like-illness (ILI) (fever cough or sore throat) should be excluded from school or work until at least 24 hours after becoming asymptomatic. For the purposes of this document, ILI includes seasonal influenza and probable/suspect/confirmed cases of novel H1N1 influenza.
2. Prophylaxis or furlough should be considered for asymptomatic healthcare workers who have had an unprotected close contact exposure with a person who has ILI that is suspected or confirmed to be novel H1N1 influenza.
3. Emphasize the importance of hand hygiene, cough etiquette, and respiratory hygiene.
*Close Contact exposure: For definition see 05.19.09 H1N1 Influenza Clinical Guidelines-Revision 4

For questions on the content of this advisory please contact NH DHHS Communicable Disease Control at 603-271-4496 or toll free at 800-852-3345, ext. 4496.

For more information about H1N1 influenza in NH, visit the NH DHHS website at:
http://www.dhhs.state.nh.us/DHHS/DHHS_SITE/swineflu.htm
For more information about H1N1 influenza, visit the CDC website at:
http://www.cdc.gov/h1n1flu/guidance/
Attachments: CDC HAN 7.9.09 Three Reports of Oseltamivir Resistant Novel Influenza A (H1N1)
Virus 07.09.09 and new NH Public Health Laboratories requisition form