Interim Guidance—HIV-Infected Adults and Adolescents: Considerations for Clinicians Regarding Swine-Origin Influenza A (H1N1) Virus

Page last updated April 30, 12:45 PM ET

Human infections with a swine-origin influenza A (H1N1) virus that is transmissible among humans were first identified in April 2009 with cases in the United States and Mexico. The epidemiology and clinical presentations of these infections are currently under investigation. There are insufficient data available at this point to determine who is at higher risk for complications of swine-origin influenza A (H1N1) virus infection. However, adults and adolescents with HIV infection, especially persons with low CD4 cell counts, are known to be at higher risk for viral and bacterial lower respiratory tract infections and for recurrent pneumonias.

Evidence that influenza can be more severe for HIV-infected adults and adolescents comes from studies among HIV-infected persons who had seasonal influenza; these data are limited. However, several studies have reported higher hospitalization rates, prolonged illness and increased mortality, especially among persons with AIDS. Thus, immune compromised persons, including HIV-infected adults and adolescents and especially persons with low CD4 cell counts or AIDS can experience more severe complications of seasonal influenza and it is possible that HIV-infected adults and adolescents are also at higher risk for swine-origin influenza complications.
Clinical Presentation

HIV-infected adults and adolescents with swine-origin influenza would be expected to present with typical acute respiratory illness (e.g., cough, sore throat, rhinorrhea) and fever or feverishness, headache, and muscle aches. For some HIV-infected persons, especially persons with low CD4 cell counts, illness might progress rapidly, and might be complicated by secondary bacterial infections including pneumonia. HIV-infected persons who have suspected swine-origin influenza A (H1N1) virus infection should be tested (see Guidance on Specimen Collection), and specimens from HIV-infected persons who have unsubtypeable influenza A virus infections should be sent to the state public health laboratory for additional testing to identify swine-origin influenza A (H1N1).

Persons with HIV infection should remain vigilant for the signs and symptoms of influenza, as outlined above. Persons with HIV infection who are concerned that they might be experiencing signs or symptoms of influenza infection, or who are concerned they might have been exposed to a confirmed, probable or suspected case of influenza infection, either seasonal influenza or swine-origin influenza A (H1N1), should consult their healthcare provider to assess the need for evaluation and for possible anti-influenza treatment or prophylaxis.

Treatment and chemoprophylaxis
The currently circulating swine-origin influenza A (H1N1) virus is sensitive to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir, but is resistant to the adamantane antiviral medications, amantadine and rimantadine. HIV-infected adults and adolescents who meet current case-definitions for confirmed, probable or suspected swine-origin influenza A (H1N1) infection (see Guidance on Case Definitions) should receive empiric antiviral treatment. HIV-infected adults and adolescents who are close contacts of persons with probable or confirmed cases of swine-origin influenza A (H1N1) should receive antiviral chemoprophylaxis. Antiviral chemoprophylaxis with either oseltamivir or zanamivir can be considered for HIV-infected persons who are household close contacts of a suspected case.

These recommendations for treatment and chemoprophylaxis are the same ones used for others who are at higher risk of complications from influenza. As is recommended for other persons who are treated, antiviral treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of influenza symptoms, with benefits expected to be greatest if started within 48 hours of onset based on data from studies of seasonal influenza. However, some data from studies on seasonal influenza indicate benefit for hospitalized patients even if treatment is started more than 48 hours after onset. Recommended duration of treatment is five days. Recommended duration of prophylaxis is 10 days after last exposure. Oseltamivir and zanamivir treatment and chemoprophylaxis regimens recommended for HIV-infected persons are the same as those recommended for adults who have seasonal influenza. Clinicians should monitor treated patients closely and consider the need to extend therapy based on the course of illness. Recommendations for use of influenza antivirals for HIV-infected adults and adolescents might change as additional data on the benefits and risks of antiviral therapy in such persons become available.

No adverse effects have been reported among HIV-infected adults and adolescents who received oseltamivir or zanamivir. There are no known absolute contraindications for co-administration of oseltamivir or zanamivir with currently available antiretroviral medications.

Other ways to reduce risk for HIV-infected adults and adolescents
There is no vaccine available yet to prevent swine-origin influenza A (H1N1).
The risk for swine-origin influenza A (H1N1) might be reduced by taking steps to limit possible exposures to persons with respiratory infections. These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household who may be ill with swine-origin influenza virus. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. A respirator that fits snugly on the face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through a respirator for long periods of time. Interim guidances regarding means to decrease the risk of getting swine-origin influenza virus are available. These guidances will be updated as more information becomes available, including information on the risk of swine-origin influenza-related complications among HIV-infected adults and adolescents.
Patients should be reminded of the importance of maintaining their health as a means of reducing their risk of infection with influenza and improving their immune system’s ability to fight an infection should it occur. In particular, patients who are currently taking antiretrovirals or antimicrobial prophylaxis against opportunistic infections should be reminded of the importance of adhering to their prescribed treatment.

-Centers for Disease Control and Prevention

WHO raises swine flu pandemic alert to phase 5

WHO raises swine flu pandemic alert to phase 5
Global outbreak considered imminent; vaccine efforts will be ramped up

The World Health Organization raised its pandemic alert for swine flu to the second highest level Wednesday, meaning that it believes a global outbreak of the disease is imminent.

WHO Director General Margaret Chan declared the phase 5 alert after consulting with flu experts from around the world. The decision could lead the global body to recommend additional measures to combat the outbreak, including for vaccine manufacturers to switch production from seasonal flu vaccines to a pandemic vaccine.

"All countries should immediately now activate their pandemic preparedness plans," Chan told reporters in Geneva. "It really is all of humanity that is under threat in a pandemic."

A phase 5 alert means there is sustained transmission among people in at least two countries. Once the virus shows effective transmission in two different regions of the world a full pandemic outbreak would be declared.

WHO has confirmed human cases of swine flu in Mexico, the United States, Canada, Britain, Israel, New Zealand and Spain. Mexico and the U.S. have reported deaths.

"It is important to take this very seriously," Chan told a press conference watched around the globe on Wednesday. But for the average person, the term "pandemic" doesn't mean they're suddenly at greater risk.

Flu viruses are notorious for rapid mutation and unpredictable behavior, Chan warned.
As fear and uncertainty about the disease ricocheted around the globe, nations took all sorts of precautions, some more useful than others.

Britain closed a school after a 12-year-old girl was found to have the disease. Egypt slaughtered all its pigs and the central African nation of Gabon became the latest nation to ban pork imports, despite assurances that swine flu was not related to eating pork.

Cuba eased its flight ban, deciding just to block flights coming in from Mexico. And Asian nations greeted returning airport travelers with teams of medical workers and carts of disinfectants, eager to keep swine flu from infecting their continent.

In Mexico City, the epicenter of the epidemic, the mayor said Wednesday the outbreak seemed to be stabilizing and he was considering easing the citywide shutdown that closed schools, restaurants, concert halls and sports arenas.

Swine flu is suspected of killing more than 150 people in Mexico and sickening over 2,400 there.
Nearly 100 cases have now been confirmed in the U.S. across 11 states, and health officials reported Wednesday that a 23-month-old Mexican boy had died in Texas.

Across Europe, Germany confirmed three swine flu cases and Austria one, while the number of confirmed cases rose to five in Britain and ten in Spain.

WHO conducted a scientific review Wednesday to determine exactly what is known about how the disease spreads, how it affects human health and how it can be treated.

The U.S., the European Union and other countries have discouraged nonessential travel to Mexico. Cuba suspended all regular and charter flights from Mexico to the island but was still allowing airlines to return travelers to Mexico.

In Australia, officials were testing more than 100 people with flu symptoms for the virus and the government gave health authorities wide powers to contain contagious diseases.

“(We can make) sure that people are isolated and perhaps detained if they don’t cooperate and are showing symptoms,” said Health Minister Nicola Roxon.

Tracking Swine Flu around the world

Not Evidence-Based Medicine but Google maps has a nice tool for tracking swine flu:

http://maps.google.com/maps/ms?ie=UTF8&hl=en&t=p&msa=0&msid=106484775090296685271.0004681a37b713f6b5950&z=2

Swine flu resources

The NLM Office of the Disaster Information Management Research Center (DIMRC) and the librarians on the Disaster Librarians listserv (List DISASTR-OUTREACH-LIB) have been actively exchanging information all weekend. The following resources may be of use during the next several days as we watch how the Swine Flu (H1N1) moves around the world.

Here are some information resources that are frequently updated with Swine Flu outbreak and mitigation developments:

CDC web page on Swine Flu. This site is kept updated with recent facts and status on Swin Flu. There is a link on the page to the facts and figures about the current investigation.
http://www.cdc.gov/swineflu/


A transcript of the April 24 press briefing about the Swine Flu situation is located at:
http://www.cdc.gov/media/transcripts/2009/t090424.htm?s_cid=tw_epr_53

Some recent articles in the MMWR on swine flu in California.

Update: Swine Influena A (H1N1) Infections - - California and Texas, April 2009 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0424a1.htm
MMWR Morb Mortal Wkly Rep. 2009 Apr 24; 58(Dispath);1-3.

Swine Influenza A (H1N1) infection in two children--Southern California, March-April 2009 MMWR Morb Mortal Wkly Rep. 2009 Apr 24;58(15):400-2.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0421a1.htm

For those of you who follow events on social media sites, CDC has a Twitter feed that contains updates on the Swine Flu:
http://twitter.com/cdcemergency

You can also add the following RSS feed on Swine Flu to your feed reader to get regular updates:
http://www.cdc.gov/swineflu/rss/?s_cid=tw_epr_54

Latest CDC Health Advisory
http://www.cdc.gov/swineflu/pdf/HAN_042509.pdf

Information updates from World Health Organization http://www.who.int/csr/disease/swineflu/en/index.html

From NYC Health Dept - Chart: steps required to confirm suspected cases of swine flu

If you are interested in the view from overseas - European Centre for Disease Prevention and Control http://ecdc.europa.eu/

Interim Guidance for Swine Influenza A (H1N1): Taking Care of a Sick Person in Your Home

April 25, 2009 18:30 EDTThis document provides interim guidance and will be updated as needed.

Swine influenza A virus infection (swine flu) can cause a wide range of symptoms, including fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. People with swine flu also can have vomiting and diarrhea. Like seasonal flu, swine flu in humans can vary in severity from mild to severe.Severe disease with pneumonia, respiratory failure and even death is possible with swine flu infection. Certain groups might be more likely to develop a severe illness from swine flu infection, such as persons with chronic medical conditions. Sometimes bacterial infections may occur at the same time as or after infection with influenza viruses and lead to pneumonias, ear infections, or sinus infections.

The following information can help you provide safer care at home for sick persons during a flu pandemic.

How Flu Spreads
The main way that influenza viruses are thought to spread is from person to person in respiratory droplets of coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose of people nearby. Influenza viruses may also be spread when a person touches respiratory droplets on another person or an object and then touches their own mouth or nose (or someone else’s mouth or nose) before washing their hands.

People with swine flu who are cared for at home should:
-check with their health care provider about any special care they might need if they are
pregnant or have a health condition such as diabetes, heart disease, asthma, or emphysema
-check with their health care provider about whether they should take antiviral medications
-stay home for 7 days after the start of illness and fever is gone
-get plenty of rest
-drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to
keep from being dehydrated
-cover coughs and sneezes. Clean hands with soap and water or an alcohol-based hand rub
often and especially after using tissues and after coughing or sneezing into hands.
-avoid close contact with others – do not go to work or school while ill
-be watchful for emergency warning signs (see below) that might indicate you need to seek
medical attention

Medications to Help Lessen Symptoms of the Flu
Check with your healthcare provider or pharmacist for correct, safe use of medications.

Antiviral medications can sometimes help lessen influenza symptoms, but require a prescription. Most people do not need these antiviral drugs to fully recover from the flu. However, persons at higher risk for severe flu complications, or those with severe flu illness who require hospitalization, might benefit from antiviral medications. Antiviral medications are available for persons 1 year of age and older. Ask your healthcare provider whether you need antiviral medication.

Influenza infections can lead to or occur with bacterial infections. Therefore, some people will also need to take antibiotics. More severe or prolonged illness or illness that seems to get better, but then gets worse again may be an indication that a person has a bacterial infection. Check with your healthcare provider if you have concerns.

Warning! Do not give aspirin (acetylsalicylic acid) to children or teenagers who have the flu; this can cause a rare but serious illness called Reye’s syndrome.
For more information about Reye’s syndrome, visit the National Institute of Health website at http://www.ninds.nih.gov/disorders/reyes_syndrome/reyes_syndrome.htm
Check ingredient labels on over-the-counter cold and flu medications to see if they contain aspirin.

Teenagers with the flu can take medicines without aspirin, such as acetaminophen (Tylenol®) and ibuprofen (Advil®, Motrin®, Nuprin®), to relieve symptoms.

Children younger than 2 years of age should not be given over-the-counter cold medications without first speaking with a healthcare provider.

The safest care for flu symptoms in children younger than 2 years of age is using a cool-mist humidifier and a suction bulb to help clear away mucus.

Fevers and aches can be treated with acetaminophen (Tylenol®) or ibuprofen (Advil®, Motrin®, Nuprin®) or nonsteroidal anti-inflammatory drugs (NSAIDS). Examples of these kinds of medications include:
Generic Name Brand Name(s)
Acetaminophen Tylenol®
Ibuprofen Advil®, Motrin®, Nuprin®
Naproxen Aleve

Over-the-counter cold and flu medications used according to the package instructions may help lessen some symptoms such as cough and congestion. Importantly, these medications will not lessen how infectious a person is.

Check the ingredients on the package label to see if the medication already contains acetaminophen or ibuprofen before taking additional doses of these medications—don’t double dose! Patients with kidney disease or stomach problems should check with their health care provider before taking any NSAIDS.

Check with your health care provider or pharmacist if you are taking other over-the-counter or prescription medications not related to the flu.For more information on products for treating flu symptoms, see the FDA website: http://www.fda.gov/fdac/features/2005/105_buy.html.

When to Seek Emergency Medical Care
Get medical care right away if the sick person at home:
-has difficulty breathing or chest pain
-has purple or blue discoloration of the lips
-is vomiting and unable to keep liquids down
-has signs of dehydration such as dizziness when standing, absence of urination, or in
infants, a lack of tears when they cry
-has seizures (for example, uncontrolled convulsions)
-is less responsive than normal or becomes confused

Steps to Lessen the Spread of Flu in the Home
When providing care to a household member who is sick with influenza, the most important ways to protect yourself and others who are not sick are to:

-keep the sick person away from other people as much as possible (see “placement of the sick
person at home”)
-remind the sick person to cover their coughs, and clean their hands with soap and water or
an alcohol-based hand rub often, especially after coughing and/or sneezing.
-have everyone in the household clean their hands often, using soap and water or an alcohol-
based hand rub
-ask your healthcare provide if household contacts of the sick person, particularly those
contacts that may have chronic health conditions, should take antiviral medications such as
oseltemivir (Tamiflu®) or zanamivir (Relenza®) to prevent the flu.

Placement of the sick person
-Keep the sick person in a room separate from the common areas of the house. (For example,
a spare bedroom with its own bathroom, if that’s possible.) Keep the sickroom door closed.
-Unless necessary for medical care, persons with the flu should not leave the home when they
have a fever or during the time that they are most likely to spread their infection to others
(7 days after onset of symptoms in adults, and 10 days after onset of symptoms in children).
-If persons with the flu need to leave the home (for example, for medical care), they should
cover their nose and mouth when coughing or sneezing and wear a loose-fitting (surgical)
mask if available.
-Have the sick person wear a surgical mask if they need to be in a common area of the house
near other persons.
-If possible, sick persons should use a separate bathroom. This bathroom should be cleaned
daily with household disinfectant (see below).

Protect other persons in the home
-The sick person should not have visitors other than caregivers. A phone call is safer than a
visit.
-If possible, have only one adult in the home take care of the sick person.
-Avoid having pregnant women care for the sick person. (Pregnant women are at increased
risk of influenza-related complications and immunity can be suppressed during pregnancy).
-All persons in the household should clean their hands with soap and water or an alcohol-
based hand rub frequently, including after every contact with the sick person or the person’s
room or bathroom.
-Use paper towels for drying hands after hand washing or dedicate cloth towels to each
person in the household. For example, have different colored towels for each person.
-If possible, consideration should be given to maintaining good ventilation in shared household
areas (e.g., keeping windows open in restrooms, kitchen, bathroom, etc.).
-Antivirals can be used to prevent the flu, so check with your healthcare provider to see if
some persons in the home should use antiviral medications.

If you are the caregiver
-Avoid being face-to-face with the sick person.
-When holding small children who are sick, place their chin on your shoulder so that they will
not cough in your face.
-Clean your hands with soap and water or use an alcohol-based hand rub after you touch the
sick person or handle used tissues, or laundry.
-Caregivers might catch flu from the person they are caring for and then the caregiver might
be able to spread the flu to others before the caregiver shows symptoms. Therefore, the
caregiver should wear a mask when they leave their home to keep from
spreading flu to others in case they are in the early stages of infection.
-Talk to your health care provider about taking antiviral medication to prevent the caregiver
from getting the flu.
-Monitor yourself and household members for flu symptoms and contact a
telephone hotline or health care provider if symptoms occur.

Using Facemasks or Respirators
-Avoid close contact (less than about 6 feet away) with the sick person as much as possible.
-If you must have close contact with the sick person (for example, hold a sick infant), spend
the least amount of time possible in close contact and try to wear a facemask (for example,
surgical mask) or N95 disposable respirator.
- An N95 respirator that fits snugly on your face can filter out small particles that can be
inhaled around the edges of a facemask, but compared with a facemask it is harder to
breathe through an N95 mask for long periods of time. More information on facemasks and
respirators can be found at www.cdc.gov/swineflu
-Facemasks and respirators may be purchased at a pharmacy, building supply or hardware
store.
-Wear an N95 respirator if you help a sick person with respiratory treatments using a
nebulizer or inhaler, as directed by their doctor. Respiratory treatments should be
performed in a separate room away from common areas of the house when at all possible.
-Used facemasks and N95 respirators should be taken off and placed immediately in the
regular trash so they don’t touch anything else.
-Avoid re-using disposable facemasks and N95 respirators if possible. If a reusable fabric
facemask is used, it should be laundered with normal laundry detergent and tumble-dried in
a hot dryer.
-After you take off a facemask or N95 respirator, clean your hands with soap and water or an
alcohol-based hand sanitizer.

Household Cleaning, Laundry, and Waste Disposal
-Throw away tissues and other disposable items used by the sick person in the trash. Wash
your hands after touching used tissues and similar waste.
-Keep surfaces (especially bedside tables, surfaces in the bathroom, and toys for children)
clean by wiping them down with a household disinfectant according to directions on the
product label.
-Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned
separately, but importantly these items should not be shared without washing thoroughly
first.
-Wash linens (such as bed sheets and towels) by using household laundry soap and tumble
dry on a hot setting. Avoid “hugging” laundry prior to washing it to prevent contaminating
yourself. Clean your hands with soap and water or alcohol-based hand rub right after
handling dirty laundry.
-Eating utensils should be washed either in a dishwasher or by hand with water and soap.

For More Information
The Centers for Disease Control and Prevention (CDC) Hotline (1-800-CDC-INFO) is available in English and Spanish, 24 hours a day, 7 days a week.

-Links to non-federal organizations are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of the individual organization Web pages found at these links.

Swine Flu

Swine flu is a type of virus. It's named for a virus that pigs can get. People do not normally get swine flu, but human infections can and do happen. The virus is contagious and can spread from human to human. Symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue.

There are antiviral medicines you can take to prevent or treat swine flu. There is no vaccine available right now to protect against swine flu. You can help prevent the spread of germs that cause respiratory illnesses like influenza by covering your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

Washing your hands often with soap and water, especially after you cough or sneeze. You can also use alcohol-based hand cleaners.

Avoiding touching your eyes, nose or mouth. Germs spread this way. Try to avoid close contact with sick people. Staying home from work or school if you are sick.

Centers for Disease Control and Prevention

Atherton Library celebrates National Library Week

View photos of Atherton Library's National Library Week celebration!

Click link:
http://www.flickr.com/photos/hpulibraries07/sets/72157617102384536/

Distance No Bar to Kidney Transplants in Remote Areas

Finding contradicts belief that process favors people in urban areas

HealthDay
By Robert Preidt
Tuesday, April 21, 2009

TUESDAY, April 21 (HealthDay News) -- People with kidney failure who live in rural or remote areas are not less likely to get a kidney transplant than people in urban areas, a new study finds.
Researchers analyzed U.S. data on 699,751 adults with kidney failure who were placed on a kidney transplant list between 1995 and 2007. After about two years on the list, 122,785 (17.5 percent) of them had received a transplant. Median distance to the closest transplant center was 15 miles.

In contrast to their pre-study theory that people who lived farthest from a transplant center were less likely to get a transplant, "the likelihood of receiving a kidney transplant from a deceased or living donor among patients living farther away was similar to or greater than those residing within 15 miles of kidney transplant centers," the study authors wrote. "Similarly, and again in contrast to our hypotheses, the adjusted likelihood of kidney transplant was slightly lower among rural dwellers."

The study is in this week's issue of the Journal of the American Medical Association.
"Although unexpected, our findings are encouraging because determining eligibility for kidney transplantation is a logistically challenging process that requires sequential diagnostic tests and encounters with health-care clinicians," wrote Dr. Marcello Tonelli, of the University of Alberta, Edmonton, Canada, and colleagues. "The finding that time to transplantation is similar or even shorter among remote- and rural-dwelling patients with kidney failure suggests that disparities in access for remote- and rural-dwellers with other diseases could be reduced or eliminated."
"These data suggest that efforts to improve equitable access to transplantation should not focus on populations defined solely by residence location," the researchers concluded.

Breast-Feeding Benefits Mothers, Study Finds

By RONI CARYN RABIN

Most doctors agree that breast-feeding is best for babies’ health. Now a large study suggests that the practice benefits mothers as well: women who have breast-fed, it says, are at lower risk than mothers who have not for developing high blood pressure, diabetes and cardiovascular disease decades later, when they are in menopause.

The benefits increase with duration of past breast-feeding, the study found. Women who had breast-fed for more than a year in their entire lifetimes were almost 10 percent less likely than those who had never breast-fed to have had a heart attack or a stroke in their postmenopausal years. They were also less likely to have diabetes, hypertension and high cholesterol.

The study found that even those postmenopausal women who had breast-fed for just one month had lower rates of diabetes, high blood pressure and high cholesterol, although the risk of heart disease after such limited breast-feeding was comparable to that among mothers who had never breast-fed.

The research, which is to be published in the May issue of the journal Obstetrics & Gynecology, analyzed data on some 139,681 women who had enrolled in the Women’s Health Initiative, a long-term national study of postmenopausal women.

Women who reported a lifetime history of more than a year of breast-feeding were 20 percent less likely to have diabetes, 12 percent less likely to have hypertension, 19 percent less likely to have high cholesterol and 9 percent less likely to have had a heart attack or a stroke by the time they enrolled in the Women’s Health Initiative.

The new study’s chief author, Dr. Eleanor Bimla Schwarz, assistant professor of medicine at the University of Pittsburgh, said of breast-feeding, “We’ve known for a long time that it’s important for the baby’s health, but we now know it’s important for mothers’ health as well.”

Other experts cautioned, however, that while the study demonstrated an association between breast-feeding and health benefits, there was not necessarily a causal relationship. Women who breast-feed may simply lead more healthful lives than those who do not, these experts said, noting that the new analysis might not have been able to account for all the differences between the two groups.

Breast-feeders “may be healthier women who take better care of themselves,” said Dr. Nieca Goldberg, medical director of the N.Y.U. Women’s Heart Center.

“This is a nice association,” Dr. Goldberg said of the findings, “but we don’t know from the study what the physiological mechanism is.”

If there is such a mechanism, Dr. Goldberg suggested, it could lie in oxytocin, a hormone crucial to milk production. Oxytocin is known to relax blood vessels, she said, and may make them more flexible and more resistant to the buildup of plaque.

Breast-feeding is also known to play a role in healing after pregnancy, by causing uterine contractions that help restore the uterus to its original size more quickly. Further, women burn extra calories when making milk, helping them eliminate fat stores accumulated during pregnancy.

Other recent studies have suggested breast-feeding may also reduce the risk of osteoporosis and both breast and ovarian cancer, as well as Type 2 diabetes.

'Silent' heart attacks more common than thought, study says

By Elizabeth Landau
CNN

(CNN) -- Although many people think of a heart attack as a painful, sometimes fatal event, there are some heart attacks that go entirely unnoticed.

Some people may have had heart attacks without knowing it, studies show.

Undiagnosed, or "silent," heart attacks affect nearly 200,000 people in the United States annually. As many as 40 to 60 percent of all heart attacks are unrecognized, studies show.

By definition, a heart attack usually happens when a clot gets in the way of blood flow from a coronary artery to the heart. This may cause symptoms such as severe chest pain, shortness of breath, fainting and nausea. Anyone who believes that he or she is having a heart attack should seek emergency medical attention.

But sometimes a heart attack is not painful, or the person experiencing it does not recognize the symptoms as heart-related, so he or she does not go to a hospital for treatment.

Cardiologists have only recently become attuned to the prevalence of these silent heart attacks, and research on treatment is limited. The risk factors for silent heart attacks are the same as for regular heart attacks, experts say, and include smoking, diabetes, stress and family history. Watch CNN Health Files: Heart attacks »

A new study from Duke University Medical Center shows that these silent heart attacks may occur more frequently than physicians thought.

Even if a heart attack occurred in the distant past, it may still leave a signature called a Q-wave on an electrocardiogram. But there are silent heart attacks that do not have associated Q-waves.

Health Library
MayoClinic.com: When is discomfort a heart attack?
Researchers used a relatively new technique called delayed-enhancement cardiovascular magnetic resonance and then followed up with patients after about two years. The study was done on 185 patients who had never had a diagnosed heart attack but were suspected of having coronary artery disease.

The researchers found that 35 percent of patients had evidence of a heart attack and that silent heart attacks without Q-waves were three times more common than those that had Q-waves.

Patients with non-Q-wave silent heart attacks also had 11 times higher risk of death from any cause and a 17-fold risk of death from heart problems compared with patients without any heart damage.

But experts do not recommend that people generally be screened for silent heart attacks unless they have other heart-related problems.

"Currently, there has not been a study that has demonstrated that early identification and therapy changes how patients with unrecognized heart attacks do in the future," said Dr. Han Kim, a cardiologist at Duke University and lead author of the study. "If you don't know when an actual event occurred, it becomes difficult to prescribe therapy."

Although the study was done on a relatively small sample of people at risk of coronary artery disease, meaning the results may not apply to the general population, other cardiologists say the study has merit in adding to the knowledge of silent heart attacks.

"Ultimately, we're going to need trials to really establish what treatment works and what doesn't," said Dr. Eric Schelbert, a cardiologist at the University of Pittsburgh School of Medicine who was not involved in the study.

Treatment for someone who has had a silent heart attack is usually the same for someone who came to the hospital immediately after a heart attack, Kim said.

This may include beta blockers, statin drugs, aspirin or other medications, Schelbert said.

Schelbert said he has seen plenty of patients who have had silent heart attacks; in fact, he has treated some of his own colleagues who have experienced them.


"It's an incredibly important thing that the physician scientist community needs to explore further," he said.

Researchers noted that patients with non-Q-wave silent heart attacks were also generally older and were more likely to have diabetes. There needs to be more of a focus on prevention among these risk groups, said Dr. David Wiener, a cardiologist at the Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, who was not involved in the study.

Aspirin Linked to Brain Microbleeds

Significance unclear, expert says
HealthDay

Monday, April 13, 2009

MONDAY, April 13 (HealthDay News) -- A Dutch study finds an increased incidence of tiny bleeding episodes in the brains of people who regularly take aspirin.

Magnetic resonance imaging (MRI) examinations of 1,062 people found a 70 percent higher incidence of "microbleeds" among those taking aspirin or carbasalate calcium, a close chemical relative of aspirin, than among those not taking such anti-clotting drugs, according to an April 13 online report in the Archives of Neurology from physicians at Erasmus MC University Medical Center in Rotterdam. The research was expected to be published in the June print issue of the journal.

No increased incidence of microbleeds was seen in people taking clot-preventing drugs that act in different ways, such as heparin, the researchers noted.

Both aspirin and carbasalate calcium are taken to reduce the risk of cardiovascular problems such as heart attack and stroke. Both prevent formation of clots by acting against platelets, the blood cells that form clots.

The report adds information to a still unfolding medical story about the causes and effects of microbleeds, said Dr. Steven M. Greenberg, a professor of neurology at Harvard Medical School and director of the Hemorrhagic Stroke Research Program at Massachusetts General Hospital.

"They found an association between taking antiplatelet medications and having microbleeds," Greenberg said. "That is not proof that the antiplatelet medications are causing the microbleeds. People typically are given antiplatelet medication because they have more cardiovascular risk factors, which are associated with microbleeds. They tried to adjust for those risk factors, but that doesn't prove that taking the medications causes the microbleeds."

And then, "it is not clear at this point what significance we can attach to seeing microbleeds," Greenberg said. Some studies have shown an association between microbleeds and an increased risk of major bleeding events in the brain, but those studies have included only small numbers of people, he added.

There also is some data indicating that microbleeds are associated with reduced brain function, but their role is unclear, because "they tend to travel together with other kinds of small-vessel brain disease," Greenberg said.

"It's not clear at this point whether microbleeds are doing any substantial harm to the brain, but we do know that antiplatelet drugs help prevent heart attacks and strokes," Greenberg said.

The most that can be said is that the study "is a little bit of a warning for us to think about antiplatelet drug therapy as a risk for hemorrhagic damage to the brain," he said.

Therefore, there is no message to physicians yet about who should or should not be prescribed antiplatelet drugs such as aspirin, Greenberg said.

"It's important not to overreact until we are sure of what gives people the best combination of benefit without much risk," he said.

Children: Early Swim Lessons May Reduce Drowning

The idea might seem obvious, but some safety experts have raised concerns that teaching young children to swim may put them at higher risk by diminishing their natural fear of water or making their caregivers overconfident. The American Academy of Pediatrics, for example, recommends swimming lessons for children 5 and up but has not taken a position on lessons for younger children because not enough was known about their effect, the researchers note.

The study, which appears in The Archives of Pediatric & Adolescent Medicine, looked at drowning deaths of people ages 1 to 19 in six states over two years. Researchers compared the swimming experience of the victims with that of similarly aged children in the same county.

Led by Dr. Ruth A. Brenner of the National Institute of Child Health and Human Development, they found that swimming lessons did not increase the drowning risk for younger children and, in fact, seemed to decrease it.

But the authors cautioned that swimming lessons alone “will not prevent drowning and that even the most proficient swimmers can drown.”

Reverse Triage Increases Hospital Beds During Disaster

By Todd Neale, Staff Writer, MedPage Today
Published: April 08, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

LITTLE FALLS, N.J., April 8 -- Discharging noncritical patients appears to be an effective way to increase a hospital's capacity for emergency admissions during a public disaster, researchers found.

Explain to interested patients that this study examined the potential impact of discharging noncritical patients during a hypothetical disaster for freeing up hospital bed space.

In three hospitals in a single health system in Maryland, so-called reverse triage contributed to 50%, 55%, and 59% of the creation of surge capacity during a hypothetical disaster of short duration, Gabor Kelen, M.D., of Johns Hopkins in Baltimore, and colleagues reported online in Disaster Medicine and Public Health Preparedness.

"Making hospital beds available for victims of a mass emergency may be easier than once thought," Dr. Kelen said. "Reverse triage . . . can significantly increase surge capacity without a corresponding increase in resources."

Hospitals in the U.S. are expected to function without outside help for up to four days during a disaster.

But the researchers cited concerns about their ability to absorb large numbers of casualties. So they set out to explore how the reverse triage of low-risk patients during the first 96 hours of a hypothetical disaster would affect surge capacity.

Within a single health system in Maryland, they canvassed inpatient units for 19 weeks at a 1,017-bed inner-city university hospital, a 355-bed teaching hospital in a working class neighborhood, and a 260-bed community hospital in a mostly wealthy county.

Nurseries, pediatric units, and ICUs were excluded.

Any patients who did not require any critical intervention -- used as a proxy for a consequential medical event -- within four days of the hypothetical disaster were deemed suitable for early discharge.

Critical interventions ranged from CPR and defibrillation, major surgery, and dialysis to blood transfusion and lumbar puncture.

Of 3,491 total patients, 44% qualified for early discharge (40% at the university hospital, 47% at the teaching hospital, and 59% at the community hospital).

After accounting for normal patient discharges and full use of staffed and unstaffed beds, the researchers estimated gross surge capacity -- beds available for disaster victims only -- at 77%, 95%, and 103% for the three hospitals, respectively.

After further accounting for normal emergency but nondisaster-related admissions, the net surge capacity was 66%, 71%, and 81%, respectively.

Reverse triage accounted for the bulk of the surge bed creation at each hospital, with additional contributions from unused licensed beds, routine discharge, and unused staffed beds.

"Reverse triage offers an important new approach in the creation of surge capacity, requiring no substantial resource increment," the researchers said.

Most of the surge capacity would have been available within 24 to 48 hours in an actual disaster situation.

And, the researchers said, "an even larger percentage of patients could be safely sent home or avoid admission, should the concept of hospital at home be available during a disaster."

They acknowledged that the study did not provide a method for predicting in advance which patients are unlikely to require a critical intervention in the coming days, "but it does show that if a system predicting risk can be harnessed, it would be a powerful tool."

The findings might not apply to a longer-term disaster, such as an influenza outbreak, they said.

The study was funded in part by the Agency for Healthcare Research and Quality and by a Department of Homeland Security Center of Excellence Grant.

The authors made no financial disclosures.
Primary source: Disaster Medicine and Public Health Preparedness
Source reference:
Kelen G, et al "Creation of surge capacity by early discharge of hospitalized patients at low risk for untoward events" Disaster Med Public Health Prep 2009; DOI: 10.1097/DMP.0b013e3181a5e7cd.

April is STD Awareness Month

April is STD Awareness Month, an annual observance to raise awareness about the impact of sexually transmitted diseases (STDs) on the health of Americans and the importance of individuals discussing sexual health with their healthcare providers and, if sexually active, their partners.

STDs are a major public health issue:

CDC estimates that there are approximately 19 million new cases of STDs each year in the United States, almost half of them among young people ages 15 to 24.
STDs have an economic impact: direct medical costs associated with STDs in the United States are estimated at $15.9 billion annually.
Vaccines offer protection against two common sexually transmitted viral infections: hepatitis B and Human Papillomavirus (HPV). CDC recommends their use for people at risk.

While serious health threats from STDs cross racial and ethnic lines, disparities persist at too high a level.
Higher rates of the most commonly reported STDs persist among African-Americans and Hispanics when compared to whites.
Most STDs have been associated with increased risk of HIV transmission.

Vitamin D Pills May Prevent Fractures in Older Adults

March 31, 2009
Vital Signs
By NICHOLAS BAKALAR

Vitamin D supplements may help prevent fractures in people over 65, provided they take enough of the right kind. A new review of clinical trials appears to show a strong dose-dependent effect for vitamin D in lowering the risk for nonvertebral fractures in the elderly.

The lead author of the analysis, Heike A. Bischoff-Ferrari, a professor of medicine at the University of Zurich, said that “vitamin D in a high enough dose is not only beneficial in the frail older population, but it also works in those still living at home and able to take care of themselves.”

The researchers, writing in the March 23 issue of The Archives of Internal Medicine, reviewed 12 randomized trials that together included more than 65,000 subjects. Doses under 400 international units a day had no discernible effect, but for doses larger than that, the pooled data showed a 20 percent reduction in the risk for all nonvertebral fractures, and an 18 percent reduction for broken hips.

The type of vitamin D made a difference. The effect of vitamin D3 was significant, with a 23 percent risk reduction, but there was no significant reduction with vitamin D2. The authors suggest that D3 is more effective in maintaining blood levels of 25-hydroxyvitamin D, the active form that the supplement takes in the body.

Heart Muscle Renewed Over Lifetime, Study Finds

In a finding that may open new approaches to treating heart disease, Swedish scientists have succeeded in measuring a highly controversial property of the human heart: the rate at which its muscle cells are renewed during a person’s lifetime.

Tests of nuclear weapons in the atmosphere, which lasted until 1963, generated a radioactive form of carbon, carbon-14. The carbon-14 in carbon dioxide is breathed in by plants, turned into glucose (see equation) and enters the human diet. In the body, the carbon-14 is incorporated into new DNA, and once a new cell is made, its DNA does not change. The level of carbon-14 in the atmosphere has dropped each year since 1963 (see graph), so the exact amount in a cell marks the year the cell was born. From a cell's birth date, researchers can calculate how quickly different tissues such as the intestine, brain and heart are renewed.

Dr. Jonas Frisén of the Karolinska Institute in Stockholm.
The finding upturns what has long been conventional wisdom: that the heart cannot produce new muscle cells and so people die with the same heart they were born with.

About 1 percent of the heart muscle cells are replaced every year at age 25, and that rate gradually falls to less than half a percent per year by age 75, concluded a team of researchers led by Dr. Jonas Frisen of the Karolinska Institute in Stockholm. The upshot is that about half of the heart’s muscle cells are exchanged in the course of a normal lifetime, the Swedish group calculates. Its results are to be published Friday in the journal Science.

“I think this will be one of the most important papers in cardiovascular medicine in years,” said Dr. Charles Murry, a heart researcher at the University of Washington in Seattle. “It helps settle a longstanding controversy about whether the human heart has any ability to regenerate itself.”

If the heart can generate new muscle cells, researchers can hope to develop drugs that might accelerate the process, since the heart fails to replace cells that are killed in a heart attack.

The dogma that the heart cannot generate new muscle cells has been challenged since 1987 by a somewhat lonely skeptic, Dr. Piero Anversa, now of the Harvard Medical School. Dr. Anversa maintains that heart muscle cells are renewed so fast that a person dying at age 80 has replaced the heart four times over. Many other researchers have doubted this assertion.

Cell turnover rates can easily be measured in animals by making their cells radioactive and seeing how fast they are replaced. Such an experiment, called pulse-labeling, could not ethically be done in people. But Dr. Frisen realized several years ago that nuclear weapons tested in the atmosphere until 1963 had in fact labeled the cells of the entire world’s population.

The nuclear blasts generated a radioactive form of carbon known as carbon-14. The amount of carbon-14 in the atmosphere has gradually diminished since 1963, when above-ground tests were banned, as it has been incorporated into plants and animals or diffused into the oceans.

In the body, carbon-14 in the diet gets into the DNA of new cells and stays unchanged for the life of the cell. Because the level of carbon-14 in the atmosphere falls each year, the amount of carbon-14 in the DNA can serve to indicate the cell’s birth date, Dr. Frisen found.

Four years ago he used his new method to assess the turnover rate of various tissues in the body, concluding that the average age of the cells in an adult’s body might be as young as 7 to 10 years. But there is a wide range of ages — from the rapidly turning over cells of the blood and gut to the mostly permanent cells of the brain.

Dr. Frisen has successfully applied his method to the heart muscle cells, but had to navigate a series of technical obstacles created by the special behavior of the cells. Many have two nuclei, instead of the usual one, and within these double nuclei the DNA may be duplicated again. “I was really impressed at the level of rigor they put into this analysis,” Dr. Murry said, calling it a “scientific tour de force.”

The finding that heart muscle cells do regenerate, though at a considerably slower rate than Dr. Anversa predicted, is a “reasonable conclusion to a hotly contested issue,” Dr. Murry said. “Anversa went out on a limb, and I think he was partly right.”

Dr. Loren Field, a heart expert at the Indiana University School of Medicine, said he had found that heart muscle cells regenerated in mice at the same rate that Dr. Frisen had found in people. Despite the controversy created by Dr. Anversa’s claims, there has long been agreement that there is a low but detectable rate of cell renewal in the heart, Dr. Field said. The goal now, in his view, is “to try to tickle the system to enhance it.”

Dr. Anversa, for his part, said he was “ecstatic” at Dr. Frisen’s confirmation of his view that the heart could generate new muscle cells, but suggested that the new measurements might have underestimated the rate at which new cells are formed. Since heart muscle cells contract 70 times a minute, they seem likely to need renewing more often than Dr. Frisen’s measurements suggest, he said. “Now let’s discuss the magnitude of the process, and that will let us think about how we can apply this concept to heart failure,” Dr. Anversa said.

Dr. Frisen said he did not agree that the rate of regeneration had been underestimated. He said it would now be worth trying to understand how the regeneration of heart muscle cells was regulated.

A zebrafish, for instance, can regenerate large regions of its heart after injury, and possibly a similar response could be induced in people. It could also be that the heart does generate many new muscle cells after a heart attack but that the cells fail to establish themselves. Drugs that kept any such new cells alive could be helpful, Dr. Frisen said.

Fewer Sugary Drinks Key to Weight Loss

Cutting down on sodas, other sweet beverages may work better than eating less, study finds

HealthDay
Thursday, April 2, 2009

THURSDAY, April 2 (HealthDay News) -- When it comes to losing weight, cutting back on the calories in sugar-sweetened drinks, rather than food, may be most important.

So say researchers who found that cutting back on calories from sugary beverages -- by only one serving per day -- accounted for nearly two-and-a-half pounds of lost weight over 18 months.

"Weight loss from liquid calories is greater than loss of calorie intake from solid food," concluded lead researcher Dr. Liwei Chen, an assistant professor of epidemiology at the School of Public Health at the LSU Health Science Center in New Orleans.

One reason for this is that the body is able to self-regulate its intake of solid food. For example, if you eat too much solid food at lunch, you'll tend to eat less at dinner. But the same self-regulation is not there for what you drink, experts say. Your body does not adjust to liquid calories, so over time, you gain more weight, Chen explained.

"If you reduce your intake of beverages, particularly sugar-containing beverages, it's a simple but easy way to help you maintain your weight," Chen said. "You can avoid additional weight gain, or if you are on a diet, it's an easy, simple way to help you achieve your goals," Chen added.

One dietitian said the finding wasn't so surprising.

The study "supports what many have suspected -- liquid calories don't satisfy," said Connie Diekman, director of university nutrition at Washington University in St. Louis. "In addition, the identification that [sugar-sweetened beverages] can impact weight gain more than other liquids is an important message as Americans continue to work to lower their calories."

And if you get thirsty? "Drink water," Chen said.

The report was published in the April 1 issue of the American Journal of Clinical Nutrition.

For the study, researchers studied the diets of 810 adults 25 to 79 years old who participated in the Lifestyle Interventions for Blood Pressure Control (PREMIER) trial. People in the trial, which lasted 18 months, were randomly assigned to one of three groups: advice about lowering blood pressure; lifestyle intervention (including dieting advice and exercise to lower blood pressure); or lifestyle intervention plus a specific diet that was rich in fruits and vegetables.

In the current study, researchers specifically looked at the weight of the participants and the beverages they drank. People in PREMIER had their weight measured at six and 18 months and were quizzed about their diet by unannounced phone interviews.

Beverages were placed into seven categories: sugar-sweetened beverages (including soft drinks, fruit drinks, fruit punch, or high-calorie beverages sweetened with sugar); diet drinks such as diet soda and other diet drinks that were artificially sweetened; milk (including whole milk, 2 percent milk, 1 percent and skim); 100 percent fruit and vegetable juice; coffee and tea with sugar; coffee and tea without sugar; alcoholic beverages.

The researchers found that sugar-sweetened drinks accounted for 37 percent of all the liquid calories people in the study consumed. Among beverages, sugar-sweetened beverages were the only type of beverage type significantly associated with weight change at both the 6 and 18 months, the researchers noted.

Drinking fewer sugary drinks was more important than eating less for losing weight, the researchers found. In fact, drinking one less serving of a soft drink was associated with just over one pound of weight loss at six months and an additional weight loss of more than 1.4 pounds at 18 months.

Diekman said the findings are a reminder that little things mean a lot when it comes to weight loss.

"If one small diet change can trigger a one-half- to one-pound weight loss in six months, adding other small changes or boosting activity even 15 minutes a day could make 'healthy' more attainable," she said. "As a registered dietitian, this study indicates to me that helping people make gradual changes will help them comfortably achieve a healthier weight."

Consuming liquid calories has increased along with the obesity epidemic, Chen's group noted. In earlier studies, researchers found that 75 percent of U.S. adults could be overweight or obese by 2015, and they tied drinking sugar-sweetened beverages to the obesity epidemic.

In 2006, the nation's major soft drink companies agreed to limit the sale of sodas in U.S. schools. That deal was brokered by the Alliance for a Healthier Generation, a joint effort of the American Heart Association and the President William J. Clinton Foundation.

What to Do if You Have a Potential Rabies Exposure

Rabies is a medical urgency not an emergency, but decisions must not be delayed. Any wounds should be immediately washed and medical attention from a health care professional should be sought for any trauma due to an animal attack before considering the need for rabies vaccination.

The need for rabies vaccination should be evaluated under the advisement of your physician and/or a state or local health department official. Decisions to start vaccination, known as postexposure prophylaxis (PEP), will be based on your type of exposure, the animal you were exposed to, as well as laboratory and surveillance information for the area where the exposure occurred.

What Were You Exposed To?
Rabies virus is transmitted through specific bodily excretions and tissue. Saliva and Brain/Nervous tissue are considered infectious materials that can transmit rabies virus. If contact with either of these has occurred the type of exposure should be evaluated to determine if PEP is necessary.

Contact such as petting or handling an animal, or contact with blood, urine or feces does not constitute an exposure, and therefore no postexposure prophylaxis is needed in these situations.

Rabies virus becomes noninfectious by desiccation and ultraviolet irradiation. Different environmental conditions affect the rate at which the virus becomes inactive, but in general, if the material containing the virus is dry, the virus can be considered noninfectious.

What Type of Exposure Occurred?
Rabies is transmitted only when the virus is introduced into a bite wound, open cuts in skin, or onto mucous membranes (such as the mouth or eyes).

When an exposure has occurred, the likelihood of rabies infection varies with the nature and extent of that exposure. Under most circumstances, two categories of exposure -- bite and nonbite -- should be considered.

Bite
Any penetration of the skin by teeth constitutes a bite exposure. All bites, regardless of body site, represent a potential risk of rabies transmission, but that risk varies with the species of biting animal, the anatomic site of the bite, and the severity of the wound.

Bites by some animals, such as bats, can inflict minor injury and thus be difficult to detect.

Nonbite
Nonbite exposures from terrestrial animals rarely cause rabies. However, occasional reports of rabies transmission by nonbite exposures suggest that such exposures should be evaluated for possible PEP administration.

The contamination of open wounds, abrasions, mucous membranes, or theoretically, scratches (potentially contaminated with infectious material from a rabid animal) also constitutes a nonbite exposure.

Other contact by itself, such as petting a rabid animal and contact with blood, urine, or feces of a rabid animal, does not constitute an exposure and is not an indication for PEP.

Circumstances of Biting Incident and Vaccination Status of Exposing Animal
An unprovoked attack by an animal is more likely than a provoked attack to indicate that the animal is rabid. Bites inflicted on a person attempting to feed or handle an apparently healthy animal should generally be regarded as provoked.

Other factors to consider when evaluating a potential rabies exposure include the local rabies epidemiology in the area, the biting animal’s history and current health status (e.g., abnormal behavior, signs of illness), and the potential for the animal to be exposed to rabies (e.g., presence of an unexplained wound or history of exposure to a rabid animal).

A currently vaccinated dog, cat, or ferret is unlikely to become infected with rabies.

What kind of animal did you have contact with?
Rabies surveillance in wild animal populations tells us that the type of animal you are exposed to affects your risk of rabies. Knowing the species of animal you were exposed to will affect decisions regarding your treatment.

Additionally, based on what is known about rabies in different species, the animal may be held for observation or immediately tested providing information which will be used to determine if rabies Post Exposure Prophylaxis is necessary.

Animal Type to Postexposure Prophylaxis Table Animal Type Evaluation and Disposition of Animal Postexposure Prophylaxis Recommendations
Dogs, cats, and ferrets Healthy and available for 10 day observation Persons should not begin vaccination unless animal develops clinical signs of rabies
Rabid or suspected rabid Immediately vaccinate
Unknown (escaped) Consult public health officials
Raccoons, skunks, foxes, and most other carnivores; Bats Regarded as rabid unless animal is proven negative by laboratory test Consider immediate vaccination
Livestock, horses, rodents, rabbits and hares, and other mammals Consider individually Consult public health officials.

Bites of squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, other small rodents, rabbits, and hares almost never require rabies postexposure prophylaxis.

Domestic Dogs, Cats, and Ferrets
The likelihood of rabies in a domestic animal varies by region; hence, the need for postexposure prophylaxis also varies.

In the continental United States, rabies among dogs is reported sporadically in states with enzootic wildlife rabies.

During 2000–2004, more cats than dogs were reported rabid in the United States. The majority of these cases were associated with spillover infection from raccoons in the eastern United States. The large number of rabies-infected cats might be attributed to fewer cat vaccination laws, fewer leash laws, and the roaming habits of cats.

In many developing countries, dogs are the major vector of rabies; exposures to dogs in such countries represent an increased risk of rabies transmission.

Other Domestic Animals
In all instances of exposure to other domestic animal species, the local or state health department should be consulted before a decision is made to euthanize and test the animal or initiate postexposure prophylaxis.

Other Exotic Pet Species
Other exotic mammalian species of animals kept as pets are considered the same as other wildlife species. Consultation should be sought from local or state health departments regarding decisions on postexposure prophylaxis.

Use of rabies vaccines in these species constitutes off-label usage. Vaccination may reduce the risk of rabies in these species, but does not eliminate the risk. Efficacy of rabies vaccines have not been demonstrated in any exotic pet species, and are not licensed for these animals. Furthermore, observation periods are not recommended with these species since virus shedding periods before onset of clinical signs are unknown. Considerations should be made to the housing of the animal, its potential to be exposed to and acquire rabies, and the circumstances of the potential exposure to a human or domestic animal.

In situations where rabies is suspected in an exotic pet species (to which a human or domestic animal exposure has occurred) it is recommended to euthanize and test the animal for rabies.

Bats
Rabid bats have been documented in all 49 continental states (Hawaii is rabies free), and bats are increasingly implicated as important wildlife reservoirs for variants of rabies virus transmitted to humans.

Recent data suggest that transmission of rabies virus can occur from minor, seemingly unimportant, or unrecognized bites from bats. Human and domestic animal contact with bats should be minimized, and bats should never be handled by untrained and unvaccinated persons or be kept as pets.

In all instances of potential human exposures involving bats, the bat in question should be safely collected, if possible, and submitted for rabies diagnosis. Rabies postexposure prophylaxis is recommended for all persons with bite, scratch, or mucous membrane exposure to a bat, unless the bat is available for testing and is negative for evidence of rabies.

Postexposure prophylaxis should be considered when direct contact between a human and a bat has occurred, unless the exposed person can be certain a bite, scratch, or mucous membrane exposure did not occur.

In instances in which a bat is found indoors and there is no history of bat-human contact, the likely effectiveness of postexposure prophylaxis must be balanced against the low risk such exposures appear to present. Postexposure prophylaxis can be considered for persons who were in the same room as a bat and who might be unaware that a bite or direct contact had occurred (e.g., a sleeping person awakens to find a bat in the room or an adult witnesses a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person) and rabies cannot be ruled out by testing the bat. Postexposure prophylaxis would not be warranted for other household members.

Wild Terrestrial Carnivores (Raccoons, Skunks and Foxes)
Raccoons, skunks, foxes, and coyotes are the terrestrial animals most often infected with rabies in the United States. All bites by such wildlife must be considered a possible exposure to the rabies virus.

Postexposure prophylaxis should be initiated as soon as possible following exposure to such wildlife unless the animal has already been tested and determined not to be rabid. If postexposure prophylaxis has been initiated and subsequent testing shows that the exposing animal was not rabid, postexposure prophylaxis can be discontinued.

Signs of rabies among wildlife cannot be interpreted reliably; therefore, any such animal that exposes a person should be euthanized as soon as possible (without unnecessary damage to the head) and the brain should be submitted for rabies testing. If the results of testing are negative, the saliva can be assumed to contain no virus, and the person exposed does not require postexposure prophylaxis.

Other Wild Animals
Small rodents (e.g., squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, and mice) and lagomorphs (including rabbits and hares) are almost never found to be infected with rabies and have not been known to transmit rabies to humans. From 1990 through 1996, in areas of the country where raccoon rabies was enzootic, woodchucks (groundhogs) accounted for 93% of the 371 cases of rabies among rodents reported to CDC.

In all cases involving rodents, the state or local health department should be consulted before a decision is made to initiate postexposure prophylaxis.

The offspring of wild animals crossbred to domestic dogs and cats (wild animal hybrids) are considered wild animals by the National Association of State and Public Health Veterinarians (NASPHV) and the Council of State and Territorial Epidemiologists (CSTE). Wild animals and wild animal hybrids should not be kept as pets. In instances where wild or hybrid animals are suspected of rabies they should be euthanized and tested for rabies.

Human exposure situations involving animals maintained in United States Department of Agriculture-licensed research facilities or accredited zoological parks should be evaluated on a case-by-case basis.

Availability of the Animal for Observation or Rabies Testing
A healthy domestic dog, cat, or ferret that bites a person should be confined and observed for 10 days.

Any illness in the animal during the confinement period or before release should be evaluated by a veterinarian and reported immediately to the local public health department.

If signs suggestive of rabies develop, postexposure prophylaxis should be initiated. The animal should be euthanized and its head removed and shipped, under refrigeration, for examination by a qualified laboratory.

If the biting animal is stray or unwanted, it should either be confined and observed for 10 days or be euthanized immediately and submitted for rabies examination.

Skunks, raccoons, foxes and bats that bite humans should be euthanized and tested as soon as possible. The length of time between rabies virus appearing in the saliva and onset of symptoms is unknown for these animals and holding them for observation is not acceptable.

After exposure to wildlife in which rabies is suspected, prophylaxis is warranted in most circumstances. Because the period of rabies virus shedding in wild animal hybrids is unknown, these animals should be euthanized and tested rather than confined and observed when they bite humans.

Vaccination should be discontinued if tests of the involved animal are negative for rabies infection.

Content Source: National Center for Zoonotic, Vector-Borne, & Enteric Diseases (ZVED)