Madison Clinic
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Influenza Plan: 2012-2013

UW Medicine Influenza Updates & Resources [UW ID required]


To better handle patient triage, testing and treatment and vaccination as the influenza season approaches we have generated the following plan/guidelines for Madison Clinic patients. This plan is meant to dovetail with HMC and UW Medicine guidelines that are available on the HMC intranet. 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; all of our patients belong to this category given their HIV status. To provide guidance for the triage and treatment of our patients during the influenza season we propose the following:

STAFF AND FACULTY

1. All health care workers should maintain careful attention to hand hygiene before and after each patient encounter regardless of patient symptoms.

2. Providers and staff should wear a mask with eye protection when caring for any coughing patient.

3. Vaccination against seasonal influenza is one of the most important ways healthcare workers can protect patients and maintain their own health throughout the influenza season. Furthermore participation in the UW Medicine influenza program is required for all HMC faculty and staff.

4. Staff and faculty with symptoms consistent with influenza-like illness (ILI) should not come into work while ill.


PATIENTS WHO PRESENT TO THE CLINIC


1.  Infection control:  Once influenza is wide-spread in the community signage and masks will be placed immediately outside the elevator doors leading into the waiting room.  Patients with an influenza-like illness (ILI) are instructed to put on a mask before proceeding to the front desk and to wear it throughout the duration of their appointment.  Patients who present to the front desk wearing a mask or with symptoms of an ILI will be segregated in the south end of the waiting room and taken back to one of the exam rooms for in-take as soon as possible.  Once in the exam room droplet precautions will be instituted to prevent spread of the virus to other patients and clinic staff and specimens collected for rapid flu testing by nursing.  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.  It is essential that patients remain in droplet isolation the whole time they are in the clinic. They should not be released from isolation until they are ready to leave the clinic / hospital. Medications and all other services will be provided for them in the isolation room. All staff entering the isolation room will observe droplet precautions by wearing a mask, eye protection and gloves. A protective gown will be added if any procedures are performed that could increase cough or nasal secretions. Room decontamination will be performed per protocol after the patient leaves the clinic.

2. Testing: Rapid PCR testing for influenza is now performed using an in house assay that detects influenza A and B and RSV.  This test is run 7 days a week and has a turn-around time of several hours that enables the following test-and-treat protocol:

  • If the clinic can accommodate keeping patients in isolation until test results are known, treatment can be initially withheld and then provided only to those testing positive.
  • If the clinic cannot keep the patient in isolation (all rooms are in use or testing was performed late in the day), the patient will be given a single dose of oseltamivir in the clinic and discharged home a prescription that can be filled later, should the test be positive.  Patients should be instructed to call back later the same day or the next morning for test results.   

3.  Treatment:  Empiric treatment for influenza A and B should be oseltamivir 75 mg bid for 5 days.  The duration of treatment can be extended based on the clinical situation, however prolonged symptoms should also prompt an evaluation for complicating bacterial superinfections and a need for hospitalization. .  If there is concern for oseltamivir resistance patients should be treated with zanamivir.  Currently, the circulating influenza viruses are susceptible to oseltamivir. 

Individuals presenting with severe symptoms or those who have added risk factors for poor outcomes (see list below) should receive expedited treatment and probable hospital admission.

Severe symptoms:

i. Dyspnea or hypoxia
ii. Fever not responsive to anti-pyretics
iii. Inability to take po
iv. ILI that is not improving after 5 days
v. Signs/symptoms of bacterial super-infection

Risk factors for severe illness:

i. CD4 < 200
ii. Pulmonary disease (COPD or asthma)
iii. Heart disease (CHF or ischemic heart disease)
iv. Diabetes in poor control (A1C > 8)
v. Morbid obesity (BMI > 40)
vi. Pregnancy
vii. Renal failure (receiving dialysis)
viii. Liver disease (cirrhosis)
ix. Neurological disease (any permanent impairment including cognitive dysfunction)
x. Immunosuppression (Receiving immunosuppressive therapy [including prednisone, chemotherapy, interferon], lymphopenia)


PATIENTS WHO CALL IN FROM HOME

1.  Patients who call 2WC Triage with symptoms of a severe ILI or who have especially compromising conditions (see 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 can be advised either to come to the clinic for testing and treatment or can be treated with oseltamivir empirically by phoning a prescription in to a local pharmacy.  These patients should be advised



PROPHYLAXIS FOR NOVEL H1N1 INFLUENZA

1. Oseltamivir prophylaxis (75 mg q day for 7 days) should be provided for individuals who have close contact with others with documented disease within the previous 48 hours.

VACCINATION FOR INFLUENZA

1.  The 2011-2012 trivalent vaccines contain:

1) influenza A – California 7/2009-H1N1-pdm09,
2) influenza A – A/Victoria/361/2011 (H3N2) (replaces A/Perth/16/2009)
3) influenza B - B/Wisconsin/1/2010.  Yamagata lineage; replaces previous Victoria lineage (B/Brisbane/60/2008). 

Vaccination for influenza (with the inactivated/killed vaccine (IM), NOT the live-attenuated intra-nasal vaccine) is recommended for all our patients who do not have classic contraindications for influenza vaccination. We will assume that you grant permission for all of your patients to receive the vaccine unless you specifically tell us otherwise (all patients will be screened for contraindications prior to vaccination).

2.  Vaccination for influenza can occur at regularly scheduled clinic visits or at “walk-in” visits.  Patients can also get influenza vaccination at other venues in their communities (e.g. retail pharmacies) and should be encouraged to bring in vaccine documentation so that this can be added to their immunization records.   

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:

a.  ILI – still sick
b.  ILI – self-reported recovery – may return to work
c.   ILI – symptoms resolved – may return to work

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

UW VIROLOGY LAB
(for local data regarding influenza in the community)
http://depts.washington.edu/rspvirus/respiratory.htm

KING COUNTY PUBLIC HEALTH
http://www.kingcounty.gov/healthservices/health/communicable/
immunization/fluseason.aspx
  

www.kingcounty.gov/healthservices/health/communicable/immunization
/fluactivity.aspx


CDC
http://www.flu.gov/professional/hospital/index.html