Memo: Four cases of swine influenza confirmed in Ontario: Update for Managing Individuals and their contacts that are suspected to have the new H1N1 swine Influenza strain

To: Health Care Providers, Hospital ERs, ICPs
From: Dr. Isra Levy, Medical Officer of Health
Date: April 28, 2009, 5:30 pm
Subject: Update for Managing Individuals and their contacts who are suspected to have the new H1N1 swine” Influenza strain

You may also want to consult the web site of the Ministry of Health and Long-Term Care for the latest Important Health Notices and clinical tools and guidelines related to human swine influenza.

This document contains changes to the management of suspected H1N1 swine Influenza and answers to common questions. Ottawa Public Health (OPH) will continue to monitor epidemiological information and provincial guidelines and update local health care providers in the management of the rapidly evolving H1N1 swine Influenza situation. Other key sources of information are listed at the end of this Memo.

There are four confirmed cases of human swine flu in Ontario related to the Mexico and American situation. All four cases have a mild illness and are in the community. No one has been hospitalized. The four cases in Ontario are spread across two health units – York and Durham.

Provincial definitions

a positive travel history is onset of illness within 7 days of travel to affected areas

Severe Respiratory Illness (SRI):
    • Respiratory symptoms
      • i.e. fever over 38 C AND cough OR breathing difficulty
    • AND Radiographic evidence consistent with SRI
      • Radiographic evidence of infiltrates consistent with pneumonia or acute respiratory distress syndrome (ARDS)
    • AND no obvious alternate diagnosis
Febrile Respiratory Illness (FRI):
    • Acute onset of respiratory symptoms which includes fever and cough and may also include headache, eye pain, sore throat, arthralgia, myalgia or prostration.
Influenza-Like Illness (ILI):
    • Acute onset of respiratory illness with fever and cough (Note: In children under 5, gastrointestinal symptoms may also present; in patients under 5 and 65 and over, fever may not be prominent.) AND one or more of the following: A sore throat, arthalgia, myalgia, or prostration which could be due to influenza virus.

How do I know when a patient has severe respiratory illness (SRI)?

A patient with severe illness is someone who presents with a clinical picture that warrants assessment at a hospital and serious consideration of admission to hospital, such as for difficulty breathing or decreased level of consciousness.

What should I do with a patient who I clinically assess to have a severe respiratory illness (SRI)?

  • Send him/her to an Emergency Room (ER)
  • Verify which ER the patient will visit and call ahead to help that ER prepare.
  • Notify OPH immediately at 613-580-6744 ext 24224 on Monday to Friday, 8:30 am to 4:30 pm that you have a suspect case of ILI with a positive travel history. After hours call 3-1-1 and ask for the Public Health Manager on call.
  • Follow infection control guidelines outlined in the MOHLTC’s April 26, 2009 IHN:
      • Use hand hygiene (alcohol-based hand rub or soap and running water) for 15 seconds before and after each patient contact.
      • Wear fit tested N95 respirators within 2 metres of the patient---if an N95 mask are available, surgical masks should be worn and the patient should remain masked.
      • Use appropriate eye protection for contact with all patient secretions (goggles or face shield).
      • Wear gloves and gowns when there is a risk of contamination with respiratory secretions.
      • Place suspect patient in a private room, and avoid exposure of other patients in waiting rooms.
      • After the patient leaves, disinfect all equipment which is shared between patients and patient contact surfaces with a hospital grade disinfectant.

How do I manage patients who call or present in my office with symptoms that meet the above case definition of FRI (with non-severe illness).

  • Do a nasopharyngeal (NP) swab. Processing of swabs will be prioritized based on severity of illness and travel history. Use the OAHPP form.
  • Refer the patient to an ER if you are unable to perform an NP swab. You can obtain swabs free of charge, see Q&A below.
  • Oseltamivir (TamifluTM) or zanamivir (RelenzaTM) are recommended for treatment of H1N1 Influenza, within 48 hours of the onset of symptoms, where illness is severe or may result in complications, as with usual management of Influenza.
  • Educate your patients and their household members on the following infection control topics:
      • Hand hygiene (alcohol-based hand rub or soap and running water for 15 seconds several times a day, for example after sneezing, before touching someone, etc.)
      • Respiratory cough and sneeze etiquette
      • Social distancing (i.e. minimizing contact with family members, not going out in public)
      • Voluntarily staying away from work or school until at least 24 hours after symptoms have resolved, or 7 days have passed since onset of illness, whichever is longer
  • In your office, follow the same infection control guidelines as described for a severe respiratory illness above.
  • Notify OPH at 613-580-6744, ext. 24224.

If my patient has a positive laboratory test for Influenza A, what other education should I provide?

  • If your patient must go into the community before 7 days have passed since onset of illness or at least 24 hours after symptoms have resolved, whichever is shorter, he/she should wear a surgical mask
  • Ill patients should also use a surgical mask when within 2 metres of other persons in the household.

Should contacts of SRI or FRI cases be given prophylactic antivirals?

Prophylactic antivirals are not recommended at this time for contacts of people with SRI or FRI suspected to be due to H1N1 Influenza.

What other direction should I provide to contacts?

  • Minimize contact in the community to the greatest extent possible
  • Designate a single household family member as the ill person’s caregiver
  • Use a surgical mask when providing care for ill household members
  • Remain home at the earliest sign of illness and contact their healthcare provider

How do I manage patients who call or present in office with Influenza-Like Illness (ILI) but who do not have FRI or SRI?

Assess and treat these patients as you would normally treat ILI.

Where can I get a supply of nasopharyngeal (NP) swabs?

You can fax a request for NP swabs to the Ottawa Public Health Laboratory at 613-736- 6820. The lab will arrange for a courier service to deliver the NP swab kits to your office as soon as possible.

Where can I obtain N95 respirators for my office?

Medical supply stores carry this product.

Where can I send staff for N 95 respirator fit testing or get fit tested myself?

Some private health care Agencies provide N 95 respirator fit testing, such as Revera Health Care Services 613-728-2277 and GEM Health Care Services 613-761-7474.

What infection control precautions are needed in my office?

The College of Physicians and Surgeons of Ontario’s document on infection control in the physician’s office remains a key reference; it is found at: http://www.health.gov.on.ca/english/providers/program/infectious/diseases/ic_ipcp.html

Should asymptomatic individuals have a 2008-9 seasonal flu shot?

As this time there is no provincial recommendation in support of promoting immunization with the 2008/9 seasonal Influenza vaccine. Individuals who insist on traveling to Mexico and have not been immunized with the seasonal Influenza vaccine should be vaccinated.

Should people in the general public wear masks?

No, the Public Health Agency of Canada does not recommend that members of the general public wear masks to protect against contracting Influenza. Evidence shows that wearing masks in public is not effective for preventing transmission of Influenza. People often use masks incorrectly, or contaminate them when putting them on and taking them off, which may increase the risk of infection. We expect further direction from the province on this issue.

What should I tell my patients who are traveling to areas affected by H1N1 swine Influenza?

The Public Health Agency of Canada assesses the need for travel advisories and posts recommendations on its website. At this point, travel should be avoided to Mexico unless necessary.

As the epidemiology and provincial guidance changes, Ottawa Public Health will continue to provide health care providers with updates. The following websites are your resources for current information:
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