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

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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.