Friday Round-up

It’s 10:40 on a Friday morning, and yet for some reason it feels like late afternoon. I guess that’s the indication of a productive week. We kicked off the week by celebrating Cataract Awareness Month (make sure your patients get screened! Cataracts can lead to falls.) We answered your OASIS-C questions about SOC dates, and we passed along a message from the CDC about Influenza A.

Next week we’re going to be back with some great stuff, so be sure to check back. Before signing off, I want to mention that there is a growing presence of state home care associations on Twitter. You can find your state association, and/or follow them all at once, @mnhomecare/state-associations.

See you next week!

CDC Advisory: Influenza A

Busy day today. I’ve got just enough time left in the day to pass along this message that comes via the Minnesota Department of Health and the CDC:

Influenza A (H3N2) virus infections have been recently detected in people in a number of states across the U.S., including two small localized outbreaks. Sporadic cases of influenza and localized summer outbreaks from seasonal influenza viruses are detected each summer. Clinicians are reminded to consider influenza as a possible diagnosis when evaluating patients with acute respiratory illnesses, including pneumonia, even during the summer months. Treatment decisions should not be made on the basis of a negative rapid influenza diagnostic test result since the test has only moderate sensitivity. False positive results also can occur, particularly at times when overall influenza prevalence is low. For patients for whom laboratory confirmation is desired, or to confirm initial influenza cases in a community in which cases have been tested by rapid influenza diagnostic tests, it is recommended that reverse transcriptase -polymerase chain reaction (RT-PCR), and/or viral culture is utilized. Clinicians should use empirical treatment with influenza antiviral medications for persons hospitalized with suspected influenza, and for suspected influenza infection of any severity in high-risk individuals, regardless of influenza immunization status. Early initiation of treatment provides more optimal clinical responses, although treatment of moderate, severe, or progressive disease begun after 48 hours of symptoms can still provide benefit.

Background

During late June and July, 2010, the number of seasonal influenza A (H3) viruses reported to CDC increased slightly compared with previous months. In the first part of July, two small RT-PCR-confirmed outbreaks were detected in two non-bordering eastern counties in Iowa. The first included four of 13 members of a college sports team who became ill. Three of the four tested positive for influenza A by rapid tests and two of the three were further tested and found to be positive for influenza A (H3) by RT-PCR. The second outbreak involved nine of 12 children in a child care setting and one parent reporting influenza-like illness; two were rapid test positive for influenza A and one was PCR positive for influenza A (H3). Specimens and isolates have been sent to CDC for further characterization. None of the patients had a history of recent travel and no epidemiological links were identified between the two outbreaks.  

Between June 20 and July 23, 2010, CDC also received additional influenza A (H3) positive specimens from 11 other states along with a smaller number of sporadic samples positive for 2009 H1N1 influenza A and B viruses. Localized summer outbreaks in the United States from seasonal influenza viruses and sporadic cases of influenza are detected each summer. 

Antigenic characterization of the influenza A (H3) viruses received at CDC are pending. However, based on hemagglutinin gene sequencing data from four viruses isolated from July specimens, these viruses are expected to be antigenically similar to A/Perth/16/2009-like H3N2 viruses. An A/Perth/16/2009-like H3N2 virus is included in the 2010-11 seasonal influenza vaccine. Perth-like H3N2 viruses were first identified in early 2009, but have not yet circulated widely in the United States. Past influenza vaccines did not contain this strain, so vaccination with last year’s seasonal vaccine would not be expected to provide substantial protection against this H3N2 Perth-like strain.

Recommendations
Health care providers are reminded to consider influenza as a possible diagnosis when evaluating patients with acute respiratory illnesses, including pneumonia, even during the summer months. The neuraminidase inhibitors oseltamivir (Tamiflu(r)) and zanamivir (Relenza(r)) are currently recommended for use against circulating influenza viruses. The adamantanes (amantadine and rimantadine) are not recommended because of high levels of resistance to these drugs among recently circulating influenza A (H3) and 2009 H1N1 pandemic viruses.  

Clinical judgment is an important factor in treatment decisions for patients presenting with influenza-like illness. Prompt empiric antiviral treatment with influenza antiviral medications is recommended while results of definitive diagnostic tests are pending, or if diagnostic testing is not possible, for patients with clinically suspected influenza illness who have:

  • Illness requiring hospitalization,
  • Progressive, severe, or complicated illness, regardless of previous health status, and/or
  • Patients at increased risk for severe disease.

Persons at high risk of influenza complications include people aged 65 years and older, young children, pregnant women, people with long-term health conditions like asthma, diabetes, neurologic and neuro-developmental disorders, heart disease, and people with immunosuppressive conditions or medications.

Antiviral treatment, when clinically indicated, should not be delayed pending definitive laboratory confirmation of influenza. Influenza antiviral medications are most effective when initiated within the first 2 days of illness, but these medications may also provide benefits for severely ill patients when initiated even after 2 days. Point of care rapid tests capable of detecting influenza A and B virus infections are available, but health care providers and public health personnel should be aware that rapid influenza diagnostic tests have limited sensitivity and false negative results are common. Thus, negative results from rapid influenza diagnostic test should not be used to guide decisions regarding treating patients with influenza antiviral medications. In addition, false positive tests can occur and are more likely when influenza is rare in the community. When laboratory confirmation is desired, testing by RT-PCR and/or viral culture is recommended.  

Providers are asked to report unusual increases in febrile respiratory disease outbreaks to their local and state health departments and to confirm positive rapid test results with PCR or culture when community circulation of influenza viruses is low.

For More Information

More information on influenza prevention, diagnosis and treatment can be found at www.cdc.gov/flu.

Be safe this flu season, dear readers!

New interim CDC guidelines for infection control

Yesterday’s humidity is gone…yay. On to some news:

The CDC has issued new recommendations for protecting health care personnel from influenza emphasize the importance of prevention. There is a comment period at this time so that providers can weigh in on the changes. Comments can be emailed to ICUpubliccomments@cdc.gov on or before July 22, 2010. CDC will review and consider all of the comments received during the comment period and then will publish a final version of the guidance before the 2010-2011 influenza season. To learn more about the recommendations, go to:
http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

Falls prevention = traumatic brain injury prevention

Falls prevention is a big part of our job as home health care workers, and for good reason: falls lead to costly hosptial stays, cause hip fractures that lead to decreased independence, and even cause death. But that’s not all: falls are the leading cause of traumatic brain injury in adults over the age of 75.

I think we all know the basics of falls prevention (although it never hurts to go over them again):

  • Make sure that stairs and floors are clear of objects that could cause your patient to trip.
  • Make sure there are no loose rugs
  • Improve lighting
  • Add non slip mats to the bath tub
  • Install hand rails
  • Check medications to make sure they aren’t causing dizziness
  • Encourage the patient to exercise–Tai Chi is often recommended as it helps improve balance.

It is also very important to recognize the signs and symptoms of a TBI in the event of a fall. They are:

(From the CDC)

Mild TBI

  • Low grade headache that does not subside
  • Difficulty remembering things
  • Slowness in thinking, speaking, or reading
  • Getting lost or easily confused
  • Lack of energy
  • Change in sleep pattern
  • Loss of balance
  • Increased sensitivity to sounds, lights and distractions
  • Blurred vision
  • Loss of sense of taste or smell
  • Ringing in the ears
  • Change in sex drive
  • Mood changes

Severe TBI

  • A headache that gets worse and does not subside
  • Vomiting
  • Convulsions or seizures
  • Inability to wake up from sleep
  • Dilation of one or both pupils
  • Slurred speech
  • Weakness or numbness in arms or legs
  • Loss of coordination
  • Increased confusion, restlessness or agitation

The CDC has all of this information in brochure and poster form, which are available for no charge. Since March is Brain Injury Awareness month, it might be a good idea to order some materials to distribute to families or to paste to your patients’ refridgerators. It never hurts to have this information on hand.

H1N1 in MN has Peaked, Possible Third Wave in January

According to the Minnesota Department of Health, H1N1 has peaked in Minnesota. This sounds like great news, but it applies only to the second wave (or second outbreak–the first was in March and April) of the virus. The MDH reports that a possible third wave may occur in January or Februrary. That being said, the CDC has downgraded its classification of the flu activity in our fair state from “widespread” to “regional”.

This information comes from the 2009 H1N1 Influenza General Talking Points, which were revised and re-released on November 24th. The document contains a great deal of interesting information. For example, it says that, while flu activity seems to have peeked in Minnesota, MDH “continues to report additional deaths from 2009 H1N1″. The document also says that deaths that are being reported as H1N1 deaths are actually not H1N1 deaths as they occur but “the completion of investigations into possible H1N1 deaths”. What that means is, if MDH reports 10 H1N1 deaths tomorrow, it doesn’t mean that those ten people died today. Rather, it’s more likely that those ten people died several weeks ago, and an investigation confirmed that their deaths were H1N1 related. It’s important to keep that in mind, especially when trying to avoid a panic.

Those of us who focus on elder care need to know that older adults are at a lower risk for H1N1 than pregnant women, children, adolescents, and younger adults. Since senior citizens–that is, people 65 and older–(unless they have underlying health conditions) are at a lower risk for the virus, they are not in the priority groups for the vaccine. They are, however, in the priority group for the vaccine for seasonal flu.

Make sure you download the talking points and read through them, and if you manage a long term care facility or home care agency, make sure you schedule some time to go over these talking points with your staff. And if any of your staff members haven’t been vaccinated, make sure that they get the H1N1 vaccine as soon as possible. It is up to health care providers to stem the spread of H1N1, and if there is a third outbreak in January, we need to be 100% prepared.

H1N1 Antiviral Treatments

Last week, the CDC released some important information about antiviral treatments for H1N1. I pulled out the key points for your convenience:

  • It is critical to remember that it is not too late to treat H1N1, even if symptoms began more than 48 hours ago.
  • Outpatients, particularly those with risk factors for severe illness who are not improving, might also benefit from treatment initiated more than 48 hours after illness onset.
  • All hospitalized patients with suspected or confirmed 2009 H1N1 should receive antiviral treatment with a neuraminidase inhibitor – either oseltamivir or zanamivir – as early as possible after illness onset.
  • Some people without risk factors may also benefit from antivirals.
    When treatment of persons with suspected 2009 H1N1 influenza is indicated, it should be started empirically. If a decision is made to test for influenza, treatment should not be delayed while waiting for laboratory confirmation.
  • Although commercially produced pediatric oseltamivir suspension is in short supply, there are ample supplies of children’s oseltamivir capsules, which can be mixed with syrup at home. In addition, pharmacies can compound adult oseltamivir capsules into a suspension for treatment of ill infants and children. Additional information on compounding can be found at: http://www.cdc.gov/H1N1flu/pharmacist/.
  • According to the CDC, the risk factors for complications with H1N1 are:

  • Asthma
  • Neurological and neurodevelopmental conditions [including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy (seizure disorders), stroke, intellectual disability (mental retardation), moderate to severe developmental delay, muscular dystrophy, or spinal cord injury].
  • Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis)
  • Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease)
  • Blood disorders (such as sickle cell disease)
  • Endocrine disorders (such as diabetes mellitus)
  • Kidney disorders
  • Liver disorders
  • Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
  • Weakened immune system due to disease or medication (such as people with HIV or AIDS, or cancer, or those on chronic steroids)
  • Another useful resource is an updated version of the Interim Guidance for Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season.

    The CDC also has free resources, including brochures and posters that you can download: http://www.cdc.gov/h1n1flu/freeresources.htm