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In This Issue:
December 27, 2013
Vol. 33, No. 22
♦ CDC Health Advisory: Early Reports of pH1N1- Page 1 of 3
Associated Il nesses for the 2013-14 Influenza WASHOE COUNTY HEALTH DISTRICT • P.O. BOX 11130 • RENO, NEVADA • 89520-0027 • (775) 328-2447 This is an official CDC HEALTH ADVISORY
Originally Distributed Via the Health Alert Network, December 24, 2013 14:30 PM ET, CDCHAN-00359 Notice to Clinicians: Early Reports of
for prevention of influenza and its complications, pH1N1-Associated Illnesses for the 2013-14
treatment with antiviral drugs (oral oseltamivir and
inhaled zanamivir) is an important second line of
Influenza Season
defense for those who become ill to reduce morbidity
and mortality. Antiviral treatment is recommended as
Summary: From November through December
early as possible for any patient with confirmed or
2013, CDC has received a number of reports of
suspected influenza who is hospitalized; has severe,
severe respiratory illness among young and middle-
complicated, or progressive illness; or is at higher
aged adults, many of whom were infected with
risk for influenza complications.
influenza A (H1N1) pdm09 (pH1N1) virus. Multiple
pH1N1-associated hospitalizations, including many Background
requiring intensive care unit (ICU) admission, and some The risk of severe disease and complications from fatalities have been reported. The pH1N1 virus that influenza is higher among children younger than 5 years emerged in 2009 caused more illness in children and of age, adults aged 65 years and older, pregnant young adults, compared to older adults, although severe women, and those with underlying medical illness was seen in all age groups. While it is not conditions. In most influenza seasons, the majority of possible to predict which influenza viruses will influenza-associated hospitalizations and deaths are predominate during the entire 2013-14 influenza season, among adults aged 65 years and older [2, 3]. However, pH1N1 has been the predominant circulating virus so during the 2009 pandemic, pH1N1 caused more illness far. For the 2013-14 season, if pH1N1 virus
in children and young adults than in older adults continues to circulate widely, illness that
[4]. This was likely due in part to protection in older disproportionately affects young and middle-aged
adults provided by cross-reactive immunity to pH1N1 adults may occur.
caused by prior infection with antigenically-related viruses. The pandemic also was notable for reports of Seasonal influenza contributes to substantial morbidity severe illness among pregnant women infected with and mortality each year in the United States. In the pH1N1 and adverse neonatal outcomes [5]. 2012-13 influenza season, CDC estimates that there were approximately 380,000 influenza-associated Early observations from the 2013-14 influenza season hospitalizations [1]. Although influenza activity nationally indicate that some persons infected with pH1N1 virus is currently at low levels, some areas of the United have had severe illness. While most of these people with States are already experiencing high activity, and severe illness have had risk factors for influenza- influenza activity is expected to increase during the next associated complications, including pregnancy and The spectrum of illness observed thus far in the 2013-14 CDC recommends annual vaccination as the best tool season has ranged from mild to severe and is consistent for prevention. However, for persons with suspected or with that of other influenza seasons. While CDC has not confirmed influenza, treatment with neuraminidase detected any significant changes in pH1N1 viruses that inhibitor antiviral drugs (oral oseltamivir and inhaled would suggest increased virulence or transmissibility, the zanamivir) can be an important component of clinical agency is continuing to monitor for antigenic and genetic care. Evidence from past influenza seasons and the changes in circulating viruses, as well as watching 2009 H1N1 pandemic has consistently shown that morbidity and mortality surveillance systems that might treatment with antiviral medications reduces severe indicate increased severity from pH1N1 virus outcomes of influenza when initiated as soon as possible infection. In addition, CDC is actively collaborating with after illness onset. Clinical trials and observational data state and local health departments in investigation and show that early antiviral treatment may (1) shorten the duration of fever and illness symptoms, (2) reduce the risk of complications from influenza (e.g., otitis media in CDC recommends annual influenza vaccination for
young children, pneumonia, respiratory failure and everyone 6 months and older. Anyone who has not yet
death), and (3) shorten the duration of hospitalization. been vaccinated this season should get an influenza vaccine now. While annual vaccination is the best tool Recommendations for Healthcare Providers
 persons aged younger than 19 years who • Clinicians should encourage all patients 6 months of are receiving long-term aspirin therapy; age and older who have not yet received an influenza vaccine this season to be vaccinated  persons who are morbidly obese (i.e., body- against influenza. There are several flu vaccine mass index is equal to or greater than 40); options for the 2013-2014 flu season (see  residents of nursing homes and other vaccine formulations this season contain a pH1N1 • Antiviral treatment can also be considered for component; CDC does not recommend one flu suspected or confirmed influenza in previously healthy, symptomatic outpatients not at high risk on • Clinicians should encourage all persons with the basis of clinical judgment, especially if treatment influenza-like illness who are at high risk for can be initiated within 48 hours of illness onset. influenza complications (see list below) to seek care Clinical judgment, on the basis of the patient’s promptly to determine if treatment with influenza underlying medical conditions, likelihood of influenza, and time since onset of symptoms, is Summary of CDC Recommendations for
important when making antiviral treatment Influenza Antiviral Medications for Health
• Decisions about starting antiviral treatment should Care Providers for the 2013-2014 Influenza
not wait for laboratory confirmation of influenza. • Rapid influenza diagnostic tests (RIDTs) have • CDC guidelines for influenza antiviral use during 2013-14 season are the same as during prior results of RIDTs do not exclude influenza virus seasons. Clinical benefit is greatest when antiviral infection in patients with signs and symptoms treatment is administered early. When indicated, suggestive of influenza. Therefore, antiviral antiviral treatment should be started as soon as treatment should not be withheld from patients with possible after illness onset, ideally within 48 hours of suspected influenza, even if they test negative. symptom onset. However, antiviral treatment might • While influenza vaccination is the best way to still be beneficial in patients with severe, prevent influenza, a history of influenza vaccination complicated, or progressive illness, and in does not rule out influenza virus infection in an ill hospitalized patients and in some outpatients when patient with clinical signs and symptoms compatible started after 48 hours of illness onset, as indicated • Antiviral treatment is recommended as early as For more information:
possible for any patient with confirmed or suspected Summary of Weekly U.S. Influenza Surveillance People at High Risk of Developing Flu–Related Complications has severe, complicated, or progressive illness; is at higher risk for influenza complications. This ACIP Recommendations for the Prevention and Control of Influenza with Vaccines, United States, 2013-14: Summary for  persons with chronic pulmonary (including Influenza Antiviral Medications: Summary for Clinicians hematological (including sickle cell disease), Guidance for Clinicians on the Use of Rapid Influenza Diagnostic Tests disorders of the brain, spinal cord, peripheral Prevention Strategies for Seasonal Influenza in Healthcare nerve, and muscle such as cerebral palsy, intellectual disability [mental retardation], Guidance for the Prevention and Control of Influenza in the muscular dystrophy, or spinal cord injury);  persons with immunosuppression, including Interim Guidance for Influenza Outbreak Management in  women who are pregnant or postpartum Patient Education: Influenza Brochures, Fact Sheets, and Posters Endnotes
1. Centers for Disease, C. and Prevention, Estimated influenza 3. Centers for Disease, C. and Prevention, Estimates of deaths illnesses and hospitalizations averted by influenza vaccination - associated with seasonal influenza --- United States, 1976-2007. United States, 2012-13 influenza season. MMWR Morb Mortal MMWR Morb Mortal Wkly Rep, 2010. 59(33): p. 1057-62. 4. Jhung, M.A., et al., Epidemiology of 2009 pandemic influenza A (H1N1) in the United States. Clin Infect Dis, 2011. 52(5): p. S13- 2. Mullooly, J.P., et al., Influenza- and RSV-associated hospitalizations among adults. Vaccine, 2007. 25(5): p. 846-55. 5. Creanga, A.A., et al., Severity of 2009 pandemic influenza A (H1N1) virus infection in pregnant women. Obstet Gynecol, 2010. Washoe County Influenza Surveillance Update, 2013-14 Influenza Season
Influenza activity in Washoe County has been steadily rising since the season officially began on September 29, 2013. The Washoe County Health District (WCHD) continues to receive weekly influenza-like illness (ILI) data from our 12 sentinel providers. Based on the data received Washoe County has exceeded the Nevada, the Regional, and the National baselines of ILI. Please see the chart below. Proportion of Patients Seen with ILI by Sentinel Physicians, Washoe County Influenza Surveillance,
2013-2014.
40 41 42 43 44 45 46 47 48 49 50 51 52
10 11 12 13 14 15 16 17 18 19 20
Washoe County
Region 9 (AZ, CA, HI, NV)
Region 9 (AZ, CA, HI, NV) Baseline
Nevada Baseline
Laboratory Evidence:
As mentioned in the CDC Health Advisory, the current predominant circulating strain of influenza nationally is pH1N1. This is also the case is Washoe County thus far. From September 29th through December 21st, the WCHD has received 220 positive laboratory results for influenza. Of the 220 positive results received, 198 are positive for influenza A, 13 are positive for influenza type unknown, and 9 are positive for influenza B. Of the 198 specimens positive for influenza A, 53 have been PCR confirmed as 2009 H1N1. Of the 53 cases that are positive for 2009 H1N1, 9 have been hospitalized. One of these hospitalized cases was admitted to ICU and placed on a ventilator. There have been no deaths reported among Washoe County residents with confirmed 2009 H1N1 to date. However, there have been out of jurisdiction fatalities related to confirmed 2009 H1N1 that occurred in Washoe County hospitals. Please see the below table for complete details: Current Week (Week 51)
Cumulative for 2013-2014 Influenza Season
#DIV/0! Denominator is zero
December 15, 2013 - December 21, 2013
September 29, 2013 - December 21, 2013
Total number of cases
reported
Additional information on influenza activity in Washoe County can be found at Please share this document with all physicians & staff in your facility/office.

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