Drugs containing benadryl linked to slowed thinking, delirium in elderly, report finds.
THURSDAY, June 4 (HealthDay News) --Older people taking common over-the-counter drugs for pain, cold symptoms or help with sleep may increase their risk for cognitive impairment, including delirium, University of Indiana researchers report.
These drugs include Benadryl, Dramamine, Excedrin PM, Nytol, Sominex, Tylenol PM and Unisom.
All of these over-the-counter (OTC) drugs contain benadryl (diphenhydramine), a molecule that blocks the neurotransmitter acetylcholine. Acetylcholine is essential for normal functioning of the central and peripheral nervous systems, the researchers explained.
"Before taking any medication prescribed by your doctor or an OTC medication, make sure there is no negative impact of this medication on your brain," said lead researcher Dr. Malaz Boustani.
His group analyzed data from 27 prior studies on the relationship between anticholinergic effects and brain function, as well as looking into anecdotal data. The team found a consistent link between anticholinergic effects and cognitive impairment in older adults.
"Any OTC medication with the term 'PM' will indicate the presence of benadryl, which is bad for the brain," Boustani concluded.
He noted that the effects of benadryl can add up, so the more medications you take that contain benadryl the worse it may be for cognition. "There is a relationship with the number of medications and the burden on your aging brain," the researcher said.
People aged 65 and older who take these medications also run the risk of developing delirium, Boustani said. Delirium is a decline in attention-focus, perception and cognition, or "acute brain failure," as Boustani calls it. Delirium typically increases the odds of dying or being institutionalized, he said.
In addition, taking these medications for 90 days or more may triple your risk of developing Alzheimer's disease, Boustani said.
Given the risks, older adults should look for drugs that don't contain benadryl, he said.
"A lot of these medications are not recognized for these side effects," he contended. "It's time for the FDA to start taking this negative impact of these medications on the aging brain seriously."
The report is published in the May online issue of the Journal of Clinical Interventions in Aging.
According to Boustani, researchers in brain pharmacoepidemiology at Indiana University's Center for Aging Research is conducting a study of 4,000 older adults to see if the long-term use of medications with anticholinergic effects is associated with the development of severe cognitive impairment, such as Alzheimer's disease.
Dr. Clinton Wright, an associate professor of neurology at the Miller School of Medicine at the University of Miami, agreed that more study is needed to assess the effects of these drugs on the brain.
"These findings don't surprise me at all," Wright said. "People tend not to think of their OTC medications as medication, but any medication that has anticholinergic effects can affect people's cognition."
Wright believes the drugs should carry a warning of this potential side effect.
Deborah G. Bolding, a spokeswoman for GlaxoSmithKline, the maker of Sominex, defended the product and said it complies with all current FDA regulations. However, she would not comment specifically on whether diphenhydramine is associated with an increased risk of delirium in older adults.
"Sominex is a mild sleep aid designed to help individuals through periods of nervous tension or stress, which are accompanied by sleeplessness. It has been proven safe and effective in medical tests when taken as directed, and has been safely used by millions of satisfied customers," Bolding said.
"For all formulations, Sominex's active ingredient is diphenhydramine hydrochloride. This is marketed under a final FDA monograph as an over-the-counter sleep aid," she added.
SOURCES: Malaz Boustani, M.D., associate professor, medicine, Indiana University School of Medicine, Indianapolis; Clinton Wright, M.D., associate professor, neurology, Miller School of Medicine, University of Miami; Deborah G. Bolding, spokeswoman, GlaxoSmithKline; May 2009, Journal of Clinical Interventions in Aging, online
Friday, June 5, 2009
Friday, May 1, 2009
CDC Health Information for International Travel 2008: Information for Travelers: Air Travel and Cruise Ships
Air Travel
Air Passengers Subject to Health Checks for Avian Influenza A (H5N1)
Transportation Security Administration – Security Measures for Air Travel, concerning what passengers may carry onto the airplane
Spraying Aircraft for Insects - DisinsectionRecommendations from Health Information for International Travel
Tuberculosis
Tuberculosis and Air Travel: Guidelines for Prevention and Control, 2nd Edition (World Health Organization, 2006) (728 KB / 47 pages)
Extensively Drug-Resistant Tuberculosis (XDR TB)
SARS
Questions and Answers about SARS and the current SARS situation
Cruise Ship Travel and Health
CDC Vessel Sanitation Program (VSP)Protects passenger and crew health by minimizing the risk of gastrointestinal illness aboard cruise ships. Posts inspection scores and outbreak information
Summary of Sanitation Inspections of International Cruise Ships ("Green Sheet")
Sanitation Inspection Scores DatabaseObtain sanitation inspection scores of international cruise ships
Cruise Ship TravelRecommendations from Health Information for International Travel
Please note: Some of these publications are available for download only as *.pdf files. These files require Adobe Acrobat Reader in order to be viewed.
Centers for Disease Control and Prevention
1600 Clifton Rd
Atlanta, GA 30333
Air Passengers Subject to Health Checks for Avian Influenza A (H5N1)
Transportation Security Administration – Security Measures for Air Travel, concerning what passengers may carry onto the airplane
Spraying Aircraft for Insects - DisinsectionRecommendations from Health Information for International Travel
Tuberculosis
Tuberculosis and Air Travel: Guidelines for Prevention and Control, 2nd Edition (World Health Organization, 2006) (728 KB / 47 pages)
Extensively Drug-Resistant Tuberculosis (XDR TB)
SARS
Questions and Answers about SARS and the current SARS situation
Cruise Ship Travel and Health
CDC Vessel Sanitation Program (VSP)Protects passenger and crew health by minimizing the risk of gastrointestinal illness aboard cruise ships. Posts inspection scores and outbreak information
Summary of Sanitation Inspections of International Cruise Ships ("Green Sheet")
Sanitation Inspection Scores DatabaseObtain sanitation inspection scores of international cruise ships
Cruise Ship TravelRecommendations from Health Information for International Travel
Please note: Some of these publications are available for download only as *.pdf files. These files require Adobe Acrobat Reader in order to be viewed.
Centers for Disease Control and Prevention
1600 Clifton Rd
Atlanta, GA 30333
Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in Healthcare Setting
April 29, 2009 09:45 PM ET
This document provides interim guidance for healthcare facilities (e.g., hospitals, long-term care and outpatient facilities, and other settings where healthcare is provided) and will be updated as needed.
Background
To date, human cases of swine influenza A (H1N1) virus infection have been confirmed in residents of several U.S. states and Mexico (for the most up-to-date list please see http://www.cdc.gov/h1n1flu/). Investigations of these cases suggest that on-going human-to-human swine influenza A (H1N1) virus is occurring. Illness signs and symptoms have consisted of influenza-like illness - fever and respiratory tract illness (cough, sore throat, runny nose), headache, muscle aches - and some cases have had vomiting and diarrhea. Cases of severe respiratory disease, including fatal outcomes, have been reported.
The swine influenza A (H1N1) virus that has infected humans in the U.S. and Mexico is a novel influenza A virus that has not previously been identified in North America. This virus is resistant to the antiviral medications amantadine and rimantadine, but is sensitive to oseltamivir and zanamivir.
Implementation of Respiratory Hygiene/Cough Etiquette
To prevent the transmission of all respiratory infections in healthcare settings, including swine influenza A (H1N1), Respiratory Hygiene/Cough Etiquette infection control measures (see http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm) should be implemented at the first point of contact with a potentially infected person. They should be incorporated into infection control practices as one component of Standard Precautions.
Healthcare facilities should establish mechanisms to screen patients for signs and symptoms of febrile respiratory illness who are presenting to any point of entry to the facility for care or making appointments to be seen at the facility. Provisions should be made to allow for prompt segregation and assessment of symptomatic patients.
Implementation of facility contingency plans
The current situation with swine flu in the United States is evolving quickly. Staff in healthcare settings should monitor http://www.cdc.gov/swineflu and state and local health department websites for the latest information. Healthcare facilities should be reviewing and making plans to implement their facility contingency response and/or pandemic response plans. This should include making plans for managing increasing patient volume and potential staffing limitations.
Interim Infection Control Recommendations
If the patient is presenting in a community where swine influenza A (H1N1) transmission is occurring (based upon information provided by state and local health departments), these infection control recommendations should apply to all patients with febrile respiratory illness (defined as fever [greater than 37.8° Celsius] plus one or more of the following: rhinorrhea or nasal congestion; sore throat; cough).
If the patient is presenting in a community without swine influenza A (H1N1) transmission, these infection control recommendations should apply to those patients with febrile respiratory illness AND:
-close contact with a person who is a confirmed, probable, or suspected case of swine influenza A (H1N1) virus infection, within the past 7 days OR
-travel to a community either within the United States or internationally where there are one or more confirmed swine influenza A (H1N1) cases within 7 days
As the situation evolves, the ability to use epidemiologic links to identify potentially infectious patients may be lost and these recommendations may need to be applied to all patients with febrile respiratory illness. This situation will be monitored, and these guidelines will be updated as needed.
Infection Control of Ill Persons in a Healthcare Setting
Screening of patients presenting to medical facilities
Patient placement and transport
Any patients who are confirmed, probable or suspected cases and present for care at a healthcare facility should be placed directly into individual rooms with the door kept closed. Healthcare personnel interacting with the patients should follow the infection control guidance in this document. For the purposes of this guidance, healthcare personnel are defined as persons, including employees, students, contractors, attending clinicians, and volunteers, whose activities involve contact with patients in a healthcare or laboratory setting.
Procedures that are likely to generate aerosols (e.g., bronchoscopy, elective intubation, suctioning, administering nebulized medications), should be done in a location with negative pressure air handling whenever feasible. An airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. Facilities should monitor and document the proper negative-pressure function of AIIRs, including those in operating rooms, intensive care units, emergency departments, and procedure rooms.
Procedures for transport of patients in isolation precautions should be followed. Facilities should also ensure that plans are in place to communicate information about suspected cases that are transferred to other departments in the facility (e.g., radiology, laboratory) and other facilities. The ill person should wear a surgical mask to contain secretions when outside of the patient room, and should be encouraged to perform hand hygiene frequently and follow respiratory hygiene / cough etiquette practices.
Limitation of healthcare personnel entering the isolation room
Healthcare personnel entering the room of a patient in isolation should be limited to those performing direct patient care.
Isolation precautions
Standard and Contact precautions plus eye protection should be used for all patient care activities for patients being evaluated or in isolation for swine influenza A (H1N1) (i.e., including all healthcare personnel who enter the patient’s room). Maintain adherence to hand hygiene by washing with soap and water or using alcohol-based hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. Nonsterile gloves and gowns along with eye protection should be donned upon room entry. (See http://www.cdc.gov/ncidod/dhqp/ppe.html)
Respiratory protection: All healthcare personnel who enter the rooms of patients in isolation for swine influenza should wear a fit-tested disposable N95 respirator or equivalent (e.g., powered air purifying respirator)*. Respiratory protection should be donned upon room entry.
Note that this recommendation differs from current infection control guidance for seasonal influenza, which recommends that healthcare personnel wear surgical masks for patient care. The rationale for the use of respiratory protection is that a more conservative approach is needed until more is known about the specific transmission characteristics of this new virus. This recommendation is also outlined in the in the in the October 2006 “Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic” http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.html.
Management of visitors
Limit visitors to patients in isolation for swine influenza A virus (H1N1) infection to persons who are necessary for the patient's emotional well-being and care. Visitors who have been in contact with the patient before and during hospitalization are a possible source of swine influenza A virus (H1N1). Therefore, schedule and control visits to allow for appropriate screening for acute respiratory illness before entering the hospital and appropriate instruction on use of personal protective equipment and other precautions (e.g., hand hygiene, limiting surfaces touched) while in the patient's room. Visitors should be instructed to limit their movement within the facility.
Visitors may be offered a gown, gloves, eye protection, and respiratory protection (i.e., N95 respirator) and should be instructed by healthcare personnel on their use before entering the patient’s room.
Duration of precautions
Isolation precautions should be continued for seven (7) days from symptom onset or until the resolution of symptoms, whichever is longer.
Persons with swine influenza A (H1N1) virus infection should be considered potentially contagious from one day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might be contagious for longer periods.
Surveillance of healthcare personnel
In communities where swine influenza A (H1N1) virus transmission is occurring, healthcare personnel should be monitored daily for signs and symptoms of febrile respiratory illness. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
In communities without swine influenza A (H1N1) virus transmission, healthcare personnel working in areas of a facility where there are patients being assessed or isolated for swine influenza infection should be monitored daily for signs and symptoms of febrile respiratory infection. This would include healthcare personnel exposed to patients in an outpatient setting or the emergency department. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
Healthcare personnel who do not have a febrile respiratory illness may continue to work. Asymptomatic healthcare personnel who have had an unprotected exposure to swine influenza A (H1N1) also may continue to work if they are started on antiviral prophylaxis. Interim guidance on antiviral recommendations for close contacts of patients with confirmed or suspected swine influenza A (H1N1) virus infection can be found at http://www.cdc.gov/h1n1flu/recommendations.htm.
Management of ill healthcare personnel
Healthcare personnel should not report to work if they have a febrile respiratory illness.In communities where swine influenza virus transmission is occurring, healthcare personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities without swine influenza virus transmission, healthcare personnel who develop a febrile respiratory illness and have been working in areas of the hospital where swine influenza patients are present, should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities where swine influenza virus transmission is not occurring, healthcare personnel who develop febrile respiratory illness and have not been in areas of the facility where swine influenza patients are present should follow facility guidelines on returning to work.
Stewardship of personal protective equipment and antivirals
Facilities should implement plans to ensure appropriate allocation of personal protective equipment, including N95 respirators, and antivirals.
Environmental infection control
Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. Management of laundry, utensils and medical waste should also be performed in accordance with procedures followed for seasonal influenza. More information can be found at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.
Facility access control
Facilities should have signage at entry points instructing patients and visitors about hospital policies, including the need to notify staff immediately if they have signs and symptoms of febrile respiratory illness. Facilities in communities where swine influenza transmission is occurring should limit points of entry to the facility..
Administration of the current 2008-2009 seasonal influenza vaccine
It is not anticipated that the seasonal influenza vaccine will provide protection against the swine flu H1N1 viruses. However, in some parts of the country, seasonal influenza viruses are still circulating. Influenza vaccination is effective against these seasonal viruses and should continue to be given to unvaccinated patients in areas where seasonal influenza cases are still occurring.
*Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Information on respiratory protection programs and fit test procedures can be accessed at http://www.osha.gov/SLTC/etools/respiratory. Staff should be medically cleared, fit-tested, and trained for respirator use, including: proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use.
Additional information on N95 respirators and other types of respirators may be found at: http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/, and at http://www.fda.gov/cdrh/ppe/masksrespirators.html.
-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.
--Centers for Disease Control and Prevention--
This document provides interim guidance for healthcare facilities (e.g., hospitals, long-term care and outpatient facilities, and other settings where healthcare is provided) and will be updated as needed.
Background
To date, human cases of swine influenza A (H1N1) virus infection have been confirmed in residents of several U.S. states and Mexico (for the most up-to-date list please see http://www.cdc.gov/h1n1flu/). Investigations of these cases suggest that on-going human-to-human swine influenza A (H1N1) virus is occurring. Illness signs and symptoms have consisted of influenza-like illness - fever and respiratory tract illness (cough, sore throat, runny nose), headache, muscle aches - and some cases have had vomiting and diarrhea. Cases of severe respiratory disease, including fatal outcomes, have been reported.
The swine influenza A (H1N1) virus that has infected humans in the U.S. and Mexico is a novel influenza A virus that has not previously been identified in North America. This virus is resistant to the antiviral medications amantadine and rimantadine, but is sensitive to oseltamivir and zanamivir.
Implementation of Respiratory Hygiene/Cough Etiquette
To prevent the transmission of all respiratory infections in healthcare settings, including swine influenza A (H1N1), Respiratory Hygiene/Cough Etiquette infection control measures (see http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm) should be implemented at the first point of contact with a potentially infected person. They should be incorporated into infection control practices as one component of Standard Precautions.
Healthcare facilities should establish mechanisms to screen patients for signs and symptoms of febrile respiratory illness who are presenting to any point of entry to the facility for care or making appointments to be seen at the facility. Provisions should be made to allow for prompt segregation and assessment of symptomatic patients.
Implementation of facility contingency plans
The current situation with swine flu in the United States is evolving quickly. Staff in healthcare settings should monitor http://www.cdc.gov/swineflu and state and local health department websites for the latest information. Healthcare facilities should be reviewing and making plans to implement their facility contingency response and/or pandemic response plans. This should include making plans for managing increasing patient volume and potential staffing limitations.
Interim Infection Control Recommendations
If the patient is presenting in a community where swine influenza A (H1N1) transmission is occurring (based upon information provided by state and local health departments), these infection control recommendations should apply to all patients with febrile respiratory illness (defined as fever [greater than 37.8° Celsius] plus one or more of the following: rhinorrhea or nasal congestion; sore throat; cough).
If the patient is presenting in a community without swine influenza A (H1N1) transmission, these infection control recommendations should apply to those patients with febrile respiratory illness AND:
-close contact with a person who is a confirmed, probable, or suspected case of swine influenza A (H1N1) virus infection, within the past 7 days OR
-travel to a community either within the United States or internationally where there are one or more confirmed swine influenza A (H1N1) cases within 7 days
As the situation evolves, the ability to use epidemiologic links to identify potentially infectious patients may be lost and these recommendations may need to be applied to all patients with febrile respiratory illness. This situation will be monitored, and these guidelines will be updated as needed.
Infection Control of Ill Persons in a Healthcare Setting
Screening of patients presenting to medical facilities
Patient placement and transport
Any patients who are confirmed, probable or suspected cases and present for care at a healthcare facility should be placed directly into individual rooms with the door kept closed. Healthcare personnel interacting with the patients should follow the infection control guidance in this document. For the purposes of this guidance, healthcare personnel are defined as persons, including employees, students, contractors, attending clinicians, and volunteers, whose activities involve contact with patients in a healthcare or laboratory setting.
Procedures that are likely to generate aerosols (e.g., bronchoscopy, elective intubation, suctioning, administering nebulized medications), should be done in a location with negative pressure air handling whenever feasible. An airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. Facilities should monitor and document the proper negative-pressure function of AIIRs, including those in operating rooms, intensive care units, emergency departments, and procedure rooms.
Procedures for transport of patients in isolation precautions should be followed. Facilities should also ensure that plans are in place to communicate information about suspected cases that are transferred to other departments in the facility (e.g., radiology, laboratory) and other facilities. The ill person should wear a surgical mask to contain secretions when outside of the patient room, and should be encouraged to perform hand hygiene frequently and follow respiratory hygiene / cough etiquette practices.
Limitation of healthcare personnel entering the isolation room
Healthcare personnel entering the room of a patient in isolation should be limited to those performing direct patient care.
Isolation precautions
Standard and Contact precautions plus eye protection should be used for all patient care activities for patients being evaluated or in isolation for swine influenza A (H1N1) (i.e., including all healthcare personnel who enter the patient’s room). Maintain adherence to hand hygiene by washing with soap and water or using alcohol-based hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. Nonsterile gloves and gowns along with eye protection should be donned upon room entry. (See http://www.cdc.gov/ncidod/dhqp/ppe.html)
Respiratory protection: All healthcare personnel who enter the rooms of patients in isolation for swine influenza should wear a fit-tested disposable N95 respirator or equivalent (e.g., powered air purifying respirator)*. Respiratory protection should be donned upon room entry.
Note that this recommendation differs from current infection control guidance for seasonal influenza, which recommends that healthcare personnel wear surgical masks for patient care. The rationale for the use of respiratory protection is that a more conservative approach is needed until more is known about the specific transmission characteristics of this new virus. This recommendation is also outlined in the in the in the October 2006 “Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic” http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.html.
Management of visitors
Limit visitors to patients in isolation for swine influenza A virus (H1N1) infection to persons who are necessary for the patient's emotional well-being and care. Visitors who have been in contact with the patient before and during hospitalization are a possible source of swine influenza A virus (H1N1). Therefore, schedule and control visits to allow for appropriate screening for acute respiratory illness before entering the hospital and appropriate instruction on use of personal protective equipment and other precautions (e.g., hand hygiene, limiting surfaces touched) while in the patient's room. Visitors should be instructed to limit their movement within the facility.
Visitors may be offered a gown, gloves, eye protection, and respiratory protection (i.e., N95 respirator) and should be instructed by healthcare personnel on their use before entering the patient’s room.
Duration of precautions
Isolation precautions should be continued for seven (7) days from symptom onset or until the resolution of symptoms, whichever is longer.
Persons with swine influenza A (H1N1) virus infection should be considered potentially contagious from one day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might be contagious for longer periods.
Surveillance of healthcare personnel
In communities where swine influenza A (H1N1) virus transmission is occurring, healthcare personnel should be monitored daily for signs and symptoms of febrile respiratory illness. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
In communities without swine influenza A (H1N1) virus transmission, healthcare personnel working in areas of a facility where there are patients being assessed or isolated for swine influenza infection should be monitored daily for signs and symptoms of febrile respiratory infection. This would include healthcare personnel exposed to patients in an outpatient setting or the emergency department. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
Healthcare personnel who do not have a febrile respiratory illness may continue to work. Asymptomatic healthcare personnel who have had an unprotected exposure to swine influenza A (H1N1) also may continue to work if they are started on antiviral prophylaxis. Interim guidance on antiviral recommendations for close contacts of patients with confirmed or suspected swine influenza A (H1N1) virus infection can be found at http://www.cdc.gov/h1n1flu/recommendations.htm.
Management of ill healthcare personnel
Healthcare personnel should not report to work if they have a febrile respiratory illness.In communities where swine influenza virus transmission is occurring, healthcare personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities without swine influenza virus transmission, healthcare personnel who develop a febrile respiratory illness and have been working in areas of the hospital where swine influenza patients are present, should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities where swine influenza virus transmission is not occurring, healthcare personnel who develop febrile respiratory illness and have not been in areas of the facility where swine influenza patients are present should follow facility guidelines on returning to work.
Stewardship of personal protective equipment and antivirals
Facilities should implement plans to ensure appropriate allocation of personal protective equipment, including N95 respirators, and antivirals.
Environmental infection control
Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. Management of laundry, utensils and medical waste should also be performed in accordance with procedures followed for seasonal influenza. More information can be found at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.
Facility access control
Facilities should have signage at entry points instructing patients and visitors about hospital policies, including the need to notify staff immediately if they have signs and symptoms of febrile respiratory illness. Facilities in communities where swine influenza transmission is occurring should limit points of entry to the facility..
Administration of the current 2008-2009 seasonal influenza vaccine
It is not anticipated that the seasonal influenza vaccine will provide protection against the swine flu H1N1 viruses. However, in some parts of the country, seasonal influenza viruses are still circulating. Influenza vaccination is effective against these seasonal viruses and should continue to be given to unvaccinated patients in areas where seasonal influenza cases are still occurring.
*Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Information on respiratory protection programs and fit test procedures can be accessed at http://www.osha.gov/SLTC/etools/respiratory. Staff should be medically cleared, fit-tested, and trained for respirator use, including: proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use.
Additional information on N95 respirators and other types of respirators may be found at: http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/, and at http://www.fda.gov/cdrh/ppe/masksrespirators.html.
-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.
--Centers for Disease Control and Prevention--
Thursday, April 30, 2009
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
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
Wednesday, April 29, 2009
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.
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.
Monday, April 27, 2009
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
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/
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/
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