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Influenza Plan: 2009-2010

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To better handle patient triage, testing and treatment and vaccination
as the influenza season approaches we have generated the follow
plan/guidelinesfor Madison Clinic patients.  This plan is meant to dovetail
with HMC and UW Medicine guidelines that are available at: 

UW Medicine Influenza Updates & Resources [UW ID required]

Current guidelines (CDC, HMC, UW) suggest that patients with severe
symptoms or who have risk factors for severe disease should be prioritized
for treatment and/or prophylaxis.  At issue is that ALL of our patients
(by virtue of HIV infection) fall into this category.  Therefore to provide
more refined guidelines for the triage and treatment of our patients during
the influenza season we propose the following:

PATIENTS WHO PRESENT TO THE CLINIC

  1. Signage (with instructions) and masks will be placed immediately
    outside the elevator doors leading into the waiting room.  Patients
    with an influenza-like illness (ILI) will be instructed to put on a mask and
    proceed to the front desk to check in.  Patients who present to the front
    desk wearing a mask or have an ILI will be segregated in the south end
    of the waiting room and taken back to one of several “flu-designated”
    exam rooms for check-in as soon as possible.
  2. If the number of patients with ILI increases dramatically we will establish
    a different routing procedure and will likely place a “greeter” at the elevator
    doors and quickly segregate and check-in those patients with an ILI in the
    north end of the waiting room.
  3. Testing for influenza virus and treatment should be linked in most cases. 
    HIV infection alone is not necessarily an indication to test and treat. 
    Instead, individuals presenting with a severe illness or those who are
    especially compromised (see below) by an underlying condition should
    be tested and treated for influenza. 

    1. Severe illness
      1. Dyspnea or hypoxia
      2. Fever not responsive to anti-pyretic
      3. Inability to take po
      4. ILI that is not improving after 5 days
      5. Signs/symptoms of bacterial superinfection
    2. Risk factors for severe illness
      1. CD4 < 200
      2. Pulmonary disease (COPD or asthma)
      3. Heart disease (CHF or ischemic heart disease)
      4. Diabetes in poor control (A1C > 8)
      5. Morbid obesity
      6. Pregnancy
      7. Renal failure (receiving dialysis)
      8. Liver disease (cirrhosis)
      9. Neurological disease (cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders)
      10. Immunosuppression (Receiving immunosuppressive
        therapy [including prednisone, chemotherapy, interferon], lymphopenia)
  4. Patients who are hypoxic or with clinical or radiographic evidence for
    pneumonia should be admitted.  Other patients should be admitted
    based on clinical judgment.
  5. Patients who are diagnosed with novel H1N1 influenza and are treated
    as outpatients should receive oseltamivir 75 mg bid for 5 days.  Patients
    who are tested for influenza and are being treated empirically before test
    results are available should receive 4 doses of oseltamivir from the
    pharmacy, a prescription for the remaining doses and told to call the
    clinic in two days for test results.  If testing is positive they should fill
    the additional prescription. If at all possible, the patient should have someone not infected with H1N1 come to the clinic to pick up the additional doses. If in your clinical judgment there is a high suspicion for H1N1, or if the patient lives so far away that repeated trips to the clinic are prohibitive, it is acceptable to give the full 5 days of oseltamivir at the initial clinic visit.
  6. It is essential that patients remain in isolation the whole time they are in the clinic. They should not be released from isolation until they are ready to entirely leave the clinic. Pharmacy and all other services will be provided for them in the isolation room.

PATIENTS AT HOME

  1. Patients who call the clinic with symptom of a severe ILI or who have
    especially compromising conditions (see #3 above) will be instructed
    to come to the clinic for evaluation, testing and treatment
  2. Patients with mild symptoms and without the conditions listed above
    will be advised to stay home, take symptomatic treatment and call back
    if their condition deteriorates

PROPHYLAXIS FOR NOVEL H1N1 INFLUENZA

  1. Oseltamivir prophylaxis (75 mg q day for 10 days) should be provided
    for individuals who meet any of the criteria above (#3 b) and who had
    close contact with others with documented disease within the last 48 hours.

VACCINATION FOR INFLUENZA

  1. Vaccination for seasonal flu and novel H1N1 influenza is recommended
    for all our patients who do not have classic contraindications for influenza vaccination.  We (providers and nurses) will assume that you grant
    permission for all of your patients to receive these vaccines unless you
    specifically tell us otherwise (all patients will be screened for
    contraindications prior to vaccination).
  2. Vaccination for seasonal influenza can occur at regularly scheduled clinic
    visits or at any of the HMC influenza clinic sessions.  Madison Clinic
    appointments specifically for influenza vaccination should not be made. 
    Patients are also encouraged to get seasonal influenza vaccination at
    other venues in their communities.
  3.  Vaccination against novel H1N1 influenza will be made available at
    the clinic as soon as it arrives.  Details will be forthcoming as we
    get them.

WORK EXCUSES FOR PATIENTS

  1. We have generated templates for the 3 common work excuse
    scenarios and can make these letters available to patients or their
    employers upon request: [UW ID required to access]

    1. ILI – still sick
    2. ILI – self-reported recovery – may return to work
    3. ILI – symptoms resolved – may return to work

Please refer to the HMC flu webpage for details regarding testing,
treatment and infection control.

UW Medicine Influenza Updates & Resources [UW ID required]

KING COUNTY PUBLIC HEALTH

  1. www.kingcounty.gov/health/h1n1
  2. Revised CDC Influenza 2009 H1N1 Antiviral Treatment Guidance
    Sept. 26, 2009

We will also be modifying our recommendations as the influenza season
evolves to respond to changes in the circulating viral strains, resistance
patterns and regional and national guidelines.