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Pandemic H1N1 (2009) influenza cases continued to be reported in Orange County.  For the latest cumulative totals of severe and fatal cases, see Updates for Orange County.

The pandemic H1N1 (2009) virus contains a unique combination of gene segments never seen before Spring 2009. The viruses are resistant to the antivirals amantadine and rimantadine, but generally susceptible to oseltamivir (Tamiflu®) and zanamivir (Relenza®). A few isolated cases with oseltamivir resistance have been reported globally and in the U.S. but there has been no evidence of ongoing transmission of these resistant viruses.  Further investigation to characterize the virus and underlying risk factors for severe disease are underway. As this situation continues to evolve, up-to-date information and guidance will be posted to http://www.cdc.gov/h1n1flu.

Surveillance in Orange County

Priorities for surveillance are now focused on severe illness (cases in intensive care unit or who have died) to detect any changes in the virulence or epidemiology of the pandemic H1N1 virus and to assess the relative contribution of seasonal and pandemic strains in severe respiratory illness in the community.  The Orange County Public Health Laboratory will continue virologic surveillance through hospitals and sentinel providers to identify circulating influenza strains (seasonal or pandemic H1N1) and other respiratory viruses causing respiratory illness in the community.

Surveillance criteria may change as the situation unfolds.  

Clinicians should send specimens* for testing for influenza through Public Health on patients who are:

Hospitalized in the intensive care unit (ICU, PICU or NICU) or who die at your facility with:

• influenza-like illness [ILI, defined as fever 37.8ºC (100ºF) and a cough and/or sore throat], OR

• pneumonia or severe, unexplained febrile respiratory illness, OR

• sepsis-like syndrome (in infants, adults >=65 years of age, or persons with compromised immune systems who may have atypical presentation for influenza);  OR

• any positive influenza test results (including tests done at another facility).

Please note that specimens and Suspect Severe Influenza Case History Forms should be sent on all patients with these symptoms who are in the ICU or who die, even if they test negative by rapid test or fluorescent antibody (DFA, IFA) test at your facility. Rapid and FA tests have had variable sensitivity for pH1N1 and false negatives have occurred. Treatment and infection control decisions should NOT rely on rapid test or FA results and should NOT be delayed pending testing results.

Public Health will accept specimens for ICU/fatal case surveillance testing only on patients meeting the above criteria. To report a suspect ICU/fatal case meeting these criteria and arrange for testing:

1. Complete a Suspect Influenza Case History Form (required) and fax to 714-834-8196.  Include copy with specimen.

2. Call 714-834-8180 during routine business hours. Cases after 5 pm on weekdays and on week-ends can be reported on the next business day.

3. Specimens should be refrigerated until pick-up.

To report an outbreak, please call Orange County Epidemiology at 714-834-8180.

Instructions on how to collect a nasopharyngeal specimen

Documents for Submitting Specimens

• Specimen collection for patients with influenza-like illness ILI

• Suspect Severe Influenza Case History Form

• Suspect Severe Influenza (including Pandemic H1N1) Case Testing Criteria

Additional Clinical Resources on Pandemic H1N1 Influenza

• Updates:  Eye on Influenza newsletter

• Management of Pandemic H1N1 Influenza Exposures to Healthcare Workers

• CDPH Lessons Learned on Pandemic (H1N1) 2009

• Alert: Novel Influenza H1N1 (swine flu) and Pregnant Women

• Information for MDs of H1N1 Patients
  This information should be reviewed and shared with your patients with suspect, confirmed or probable novel H1N1 flu.

• CDC: www.cdc.gov/H1N1flu

• Treatment and Prophylaxis (Antivirals)

  • CDPH: Updated Interim Antiviral Guidance - 7/22/09

  • CDC:  http://www.cdc.gov/h1n1flu/recommendations.htm

  • Pediatric Antiviral Dosing Update CDC 9-25-09

• Infection Control for Care of Confirmed, Probable, and Suspect Pandemic H1N1 Patients in a Healthcare Settings

  • Droplet and standard precautions, similar to what is used for seasonal influenza, are recommended by the Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), Association for Professionals in Infection Control and Epidemiology (APIC), and World Health Organization for use in caring for patients with suspect, probable or confirmed novel H1N1 except for during aerosol-generating procedures, when health care providers should also wear a N-95 respirator. The SHEA position statement is available at http://www.sheaonline.org/Assets/files/
    policy/061209_H1N1_Statement.pdf. However, the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (available at www.dir.ca.gov/oshsb/atd0.html), effective 8/5/09, requires that all health care settings in California, when providing care to patient identified as a confirmed or suspect pandemic (H1N1) 2009 influenza case, use respiratory protection that is at least effective as an N95 filtering facepiece respirator. Questions about the application of the standard should be directed to Cal/OSHA. Federal guidance is in flux and updates are expected after the Institute of Medicine makes its recommendations on 9/1/09.

  • CDC: http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

  • CDPH: Infection Control Recommendations for Hospitalized Patients

• CDPH: Q & A for long-term care facilities

• Summaries of cases and outbreaks published in MMWR available at http://www.cdc.gov/mmwr.