- Influenza vaccination & treatment
- Zika virus infection & pregnancy
- Hepatitis C & dialysis
- Crisis standards of care
Influenza vaccination & treatment
Action requested: Be aware of guidelines for influenza vaccination and treatment.
Background & Recommendations:
This is follow up to my January 20 alert, to remind providers about current guidelines. Annual influenza vaccine is recommended for everyone ages six months and older who does not have contraindications. This is critical for persons at higher risk for complications:
- Children younger than 5, but especially children younger than 2 years old
- Adults 65 years of age and older
- Pregnant women and women up to two weeks post-partum
- Residents of nursing homes and other long-term care facilities
- American Indians and Alaskan Natives
- People who have chronic medical conditions such as asthma, diabetes, or morbid obesity
Antiviral treatment is recommended as early as possible, ideally within 48 hours of symptom onset. Treatment should not be delayed while waiting for laboratory confirmation in any patient with suspected influenza who is hospitalized, has severe, complicated, or progressive illness, or is at higher risk for influenza complications. For dosing guidelines, see http://www.cdc.gov/flu/professionals/antivirals/antiviral-dosage.htm.
Zika virus infection & pregnancy
Action requested: Advise women who are pregnant or considering pregnancy in the immediate future to postpone travel to countries where Zika virus transmission is ongoing.
Background: This is a follow up to my January 19 alert. Zika virus is a mosquito-borne flavivirus transmitted primarily by Aedes aegypti mosquitoes. An estimated 80% of persons infected with Zika virus are asymptomatic and symptomatic disease is generally mild. Symptoms usually last from several days to 1 week. Severe disease requiring hospitalization is uncommon, and fatalities are rare. Guillain-Barré syndrome has been reported in patients following suspected Zika virus infection.
No locally transmitted Zika cases have been reported in the continental United States, but cases have been reported in returning travelers. Locally transmitted Zika virus has been reported in the Commonwealth of Puerto Rico. With the recent outbreaks, the number of Zika cases among travelers visiting or returning to the United States will likely increase, potentially resulting in local spread of the virus in some areas of the United States.
CDC has issued a travel notice (Level 2-Practice Enhanced Precautions) for people traveling to areas where Zika virus transmission is ongoing because of reports of microcephaly and other poor pregnancy outcomes in babies of mothers who were infected with Zika virus while pregnant. Pregnant women can be infected with Zika virus in any trimester. Maternal-fetal transmission of Zika virus has been documented throughout pregnancy, and Zika virus infections have been confirmed in infants with microcephaly. Studies are ongoing to investigate the association of Zika virus infection and fetal loss or microcephaly, including the role of other contributory factors (e.g., prior or concurrent infection with other organisms, nutrition, and environment).
- Advise pregnant patients to postpone travel to areas where Zika virus transmission is ongoing because of the potential for microcephaly and other poor pregnancy outcomes in babies of mothers infected with Zika virus while pregnant.
- Advise pregnant women who cannot postpone travel to an area with Zika virus transmission to strictly follow steps to avoid mosquito bites. Insect repellents containing DEET, picaridin, and IR3535 are considered safe for pregnant women when used as directed.
- Ask all pregnant women about recent travel.
- Test pregnant women with a history of travel to an area with Zika virus transmission AND who:
1) report two or more symptoms consistent with Zika virus disease (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) during or within 2 weeks of travel, OR,
2) have ultrasound findings of fetal microcephaly or intracranial calcifications.
Do not test asymptomatic pregnant women in the absence of fetal microcephaly or intracranial calcifications or without a travel history to an area with Zika virus transmission.
- Consider serial ultrasound examination in pregnant women with laboratory evidence of Zika virus infection to monitor fetal growth and anatomy. Referral to a maternal-fetal medicine or infectious disease specialist with expertise in pregnancy management is recommended.
- Report suspected cases to the Health District at 425-339-5278 to arrange testing at CDC.
- No specific antiviral treatment is available for Zika disease. Treatment is generally supportive and can include rest, fluids, and use of analgesics and antipyretics. Pregnant women who have a fever should be treated with acetaminophen.
For additional guidance on evaluation and testing of infants with possible congenital Zika virus infection, see http://www.cdc.gov/zika/hc-providers/index.html. Refer pregnant women with questions about Zika virus to http://www.cdc.gov/zika/pregnancy/question-answers.html
Hepatitis C & dialysis
Action requested: Be aware of an increase in acute Hepatitis C virus (HCV) infections among patients undergoing hemodialysis.
Background: In 2014 and 2015, CDC was notified of 36 cases of acute HCV infection in 19 different hemodialysis clinics (none in Washington State). HCV transmission between patients has been demonstrated at nine of those clinics, based on epidemiologic and viral sequencing evidence. Infection control lapses (e.g., injection safety, environmental disinfection, and hand hygiene) were commonly identified at these facilities. Although the exact means of transmission could not be discerned, these lapses all could potentially contribute to HCV transmission. Though the increase in acute HCV infections might be attributed in part to improved screening and awareness of the potential for HCV infection in the hemodialysis setting, this increase underscores the potential for patients to acquire serious infections during dialysis care.
Recommendations: Dialysis facilities should evaluate infection control practices and ensure strict adherence to infection control standards. If gaps are identified, promptly address any issues to protect patients’ health and safety:
For additional guidance about infection control in dialysis facilities, see http://www.cdc.gov/dialysis/.
- Provide annual training of staff to ensure adherence to infection control recommendations for hemodialysis settings. Take action to improve injection safety, hand hygiene, and routine environmental disinfection procedures.
- Screen chronic hemodialysis patients for HCV antibody upon admission to the dialysis clinic and every six months thereafter if susceptible to HCV infection. A reflex RNA test should be performed on all patients with a positive anti-HCV test result.
- Ensure patients identified to have HCV infection are aware of the diagnosis and are referred for appropriate evaluation and care. Persons with chronic HCV infection, including those with end-stage renal disease, may benefit from treatment.
- Immediately report new suspect cases of HCV infection among patients undergoing hemodialysis to the Health District at 425-339-5278.
Crisis Standards of Care
The Washington State Department of Health and the Region 9 Healthcare Coalition will host a Crisis Standards of Care workshop on April 28th from 8:00 – 11:30 am in Spokane and online. This workshop will explore the clinical, ethical, and legal frameworks of providing the best possible outcomes for the population as a whole under medical surge conditions. The keynote speaker for this workshop is Dr. John L. Hick, Faculty Emergency Medicine Physician at Hennepin County Medical Center and Associate Professor of Emergency Medicine at the University of Minnesota. The goal of this workshop is to help clinicians and other healthcare professionals understand crisis standards of care, critical aspects of decision-making, legal issues, and the role of the Washington State Disaster Medical Advisory Committee. To learn more and sign up for this event, go to https://srhd.org/documents/Providers-HCC/Crisis-Standards-of-Care-Workshop-Spokane-April-28-2016.pdf.