San Francisco Department of Public Health
Communicable Disease Control & Prevention sfdph.org/cdcp Tel (415) 554-2830 Fax (415) 554-2848 INFLUENZA HEALTH ADVISORY The San Francisco Dept. of Public Health (SFDPH) provides this guidance based on current information. Recommendations may change, and SF recommendations may differ from those issued by the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH). For updates, forms and FAQs visit
SITUATIONAL UPDATE
Based on CDPH surveillance data as of 11/1/2013, statewide and nationwide influenza activity continues to be sporadic. It is not yet known which influenza strains will predominate during the 2013-2014 influenza season. For CDPH surveillance updates see:Vaccination and good infection control practices remain the best prevention strategies.
ACTIONS REQUESTED OF ALL CLINICIANS
1. Report the following to SFDPH Disease Control at (415) 554-2830:
- outbreaks of undiagnosed influenza-like illness (ILI)* in large group or institutional settings; and - individual lab-confirmed cases of seasonal influenza only if they meet specific reporting criteria below.
2. Treat patients with suspected or confirmed influenza who are hospitalized for severe illness or who are at
higher risk for influenza-related complications. Use oseltamivir or zanamivir. Treat early and empirically, without relying on lab test results.
3. Encourage and facilitate influenza vaccination for all persons 6 months of age and older and
pneumococcal vaccination for those at increased risk of pneumococcal disease.
4. Implement infection control precautions as described on page 3 below. Note:
ALL PERSONS with fever & cough should wear a face mask in all health care settings. ALL PERSONS with ILI * should be instructed to stay at home until 24 hours after fever resolves,
except patients that require medical evaluation and care.
INFLUENZA SURVEILLANCE AND REPORTING
Goals for influenza surveillance this season are to: (a) prevent and curb outbreaks in confined settings where the risk of transmission is high; and (b) monitor the epidemiology of fatal cases of influenza.
PLEASE REPORT: A) Cases occurring among residents of group or institutional settings (e.g. long-term care, rehab, assisted living facilities, college dorms) in SF which are either: (a) lab-confirmed cases of influenza or (b) outbreaks of undiagnosed ILI. ______________________________________________________________________________________________________
*ILI (influenza-like illness) is defined by the CDC as temperature >37.8°C or 100°F and either cough or sore throat. Categories of urgency levels Health Alert: conveys the highest level of importance; warrants immediate action or attention Health Advisory: provides important information for a specific incident or situation; may not require immediate action Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action Communicable Disease Control & Prevention San Francisco Department of Public Health
Report by telephone to SFDPH (415) 554-2830 within 24 hours Infection control checklists and forms for tracking outbreaks are posted at Note: During outbreak investigations, SFDPH may request specimens for confirmatory testing
B) Fatal cases of lab-confirmed influenza in persons 0-64 yrs, whether hospitalized or not.
As soon as possible (but no later than 7 days), complete case report form (se
and fax to SFDPH at (415)554-2848 or call (415) 554-2830 to speak with an investigator
ALL influenza deaths ages 0-64 years are reportable by law in California Note: SFDPH may request retained specimens from fatal cases, which will be forwarded to CDPH for viral
culture, strain typing, antiviral resistance testing in order to characterize the circulating strains, guide antiviral treatment recommendations and look for the emergence of novel strains.
C) The following novel influenza infections are not due to seasonal influenza strains, but may occur during influenza season and must be reported to SFDPH if suspected:
Swine variant influenza: Influenza-like illness in any person with recent swine exposure or contact with a
confirmed case of swine variant influenza (e.g. H3N2v or H1N2v). For more information concerning swine variant influenza, se
Avian Influenza A: H7N9: Influenza-like illness severe enough to require inpatient medical care in a
person with recent close contact (within ≤ 10 days of illness onset) with a confirmed or probable case of infection with Avian Influenza A:H7N9 virus; OR recent travel (within ≤ 10 days of illness onset) to a country where human cases of Avian Influenza A:H7N9 virus have been recently detected OR where Avian Influenza A:H7N9 viruses are known to be circulating in animals. (China is the only country where H7N9 viruses are known to be circulating at this time.) For more information concerning Avian Influenza A:H7N9 virus, se INFLUENZA TESTING, SPECIMEN COLLECTION AND SUBMISSION
Rapid antigen tests may be useful when testing will help guide acute clinical care decisions. Reliability of tests varies. Note that a recent CDC study found that rapid flu tests have limited ability to detect variant influenza A viruses. Further information can be found at In select situations, SFDPH may perform additional testing by Polymerase Chain Reaction (PCR). ALL requests for flu testing by SFDPH must be coordinated through and approved by SFDPH Disease Control (415) 554-2830. SFDPH may test for flu by PCR among residents of large group or institutional settings, or in patients who are hospitalized with ILI. Collection of Influenza Specimens: Acceptable specimens are nasal aspirates, nasal washes, nasopharyngeal swabs, pharyngeal swabs, dual nasopharyngeal/throat swabs and lower respiratory tract specimens (broncheoalveolar lavage, bronchial wash, tracheal aspirate, sputum, and lung tissue). Specimens should be collected within the first 24-72 hours of onset of symptoms, and no later than 5 days from onset of symptoms. If submitting swabs, use Dacron with an aluminum or plastic shaft. After collection, specimens should be kept refrigerated and delivered to SFDPH Laboratory within 72 hours. Specimens that cannot be delivered to the SFDPH Laboratory within 72 hours must be frozen at -70ºC or below and shipped on dry ice. Specimens are accepted Monday - Friday, 8am to 5pm, and must be accompanied by an SFDPH lab form. Instructions and forms can be found at:html Communicable Disease Control & Prevention San Francisco Department of Public Health
VACCINE FOR INFLUENZA
2013-14 U.S. trivalent influenza vaccines contain an A/California/7/2009 (H1N1) -like virus, an A/Victoria/361/2011 (H3N2) -like virus, and a B/Massachusetts/2/2012-like virus. Quadrivalent vaccines are newly available this year, and also include a B/Brisbane/60/2008-like virus. Two other new formulations include Flucelvax, grown in canine kidney cells rather than eggs, and FluBlok, a trivalent recombinant vaccine. Intranasal, high-dose, and intradermal formulations continue to be available. A complete listing of 2013-14 flu vaccine products is posted ator
If your facility does not offer flu vaccine, patients can be referred to the AITC Immunization and Travel Clinic at SFDPH. Additional flu shot locations can be found at
Recommendations: Annual vaccination is recommended for everyone age 6 months and older, regardless of risk group, to ensure protection throughout the 2013-14 influenza season. For persons for whom more than one product is appropriate, no preferential recommendation is made for one product over another. Children age 6 months through 8 years: only 1 dose of the 2013-14 formulation is needed if child is known to have received at least 2 doses of seasonal influenza vaccine since July 1, 2010; all others in this age group need 2 doses administered at least 4 weeks apart. Pregnant women and children 6-35 months of age, as in past years, must receive flu vaccine free of the preservative thimerosal, according to California law. Persons who report allergy to eggs: recommendations revised for 2013-14 are available online at
Health Care Workers: By order of the San Francisco Health Officer dated 10/4/13, all hospitals, skilled nursing, and other long term care facilities in the City and County of San Francisco must require their health care workers to receive an annual flu vaccination or, if they decline, to wear a mask in patient care areas during the influenza season. The full document is available atn addition, CA law (Health & Safety Code §1288.7 / Cal OSHA §5199) mandates either flu vaccination or the signing of a declination form for all acute-care hospital workers and most health care personnel including clinic and office- based staff. ANTIVIRAL TREATMENT FOR INFLUENZA The CDC’s treatment recommendations have not yet been updated for the 2013-14 flu season, but are not expected to differ significantly from 2012-13 recommendations (se. Antiviral medications can reduce illness severity, shorten duration of illness and length of hospitalization, and reduce risk of complications and mortality from influenza. Treatment with oseltamivir or zanamivir is recommended for cases of suspected or confirmed influenza in:
Hospitalized patients; Persons with severe, complicated, or progressive illness; and Persons at higher risk for influenza-related complications
Those at higher risk for influenza-related complications include:
persons age <2 years or ≥65 years; persons with chronic pulmonary, cardiovascular, renal, hepatic, hematological, neurologic (including
neurodevelopmental), and metabolic disorders
persons with immunosuppression, including from medications or by HIV infection; women who are pregnant or postpartum (within 2 weeks after delivery); persons aged <19 years who are receiving long-term aspirin therapy; American Indians/Alaska Natives;
Communicable Disease Control & Prevention San Francisco Department of Public Health
persons who are morbidly obese (i.e., BMI ≥40); and residents of nursing homes and other chronic-care facilities.
Treatment should be initiated as early as possible as benefit is greatest when started within 48 hours of illness onset. However for hospitalized patients and those with severe, complicated, or progressive illness, antiviral treatment might still be beneficial if started up to 4-5 days after illness onset. Treatment decisions should be made empirically and should not await lab confirmation of influenza since testing could delay treatment and a negative rapid test does not rule out influenza. Duration of treatment is 5 days (but may be extended for those still severely ill after 5 days of treatment. Oseltamivir recently received FDA approval for treatment of infants as young as 2 weeks of age. Antiviral dosing can be found in the Prescribing Information for oseltamivir (Tamiflu) or zanamivir (Relenza). INFECTION CONTROL PRECAUTIONS FOR HEALTHCARE SETTINGS
All healthcare facilities should adopt standard and droplet precautions when caring for patients with ILI, or suspected or confirmed influenza infection. Specifically:
Request that all persons with fever and cough wear a face mask;
Isolate unmasked patients with ILI as soon as possible, ideally in a private exam room or at a distance of at
Staff entering the exam room of any patient with ILI should either ensure the patient is masked, or wear
either a face mask or N-95 respirator pending diagnosis.
There are no data to indicate that the transmission characteristics of the H1N2v or H3N2v viruses differ from those of seasonal influenza viruses. As a result, the infection control principles and actions relevant for seasonal influenza are appropriate for the control of H3N2v as well. If influenza A:H7N9 is suspected: use standard, contact and airborne precautions. For more information on infection control when influenza A: H7N9 is suspected, se SOLICITATION FOR SENTINEL PROVIDERS FOR INFLUENZA SURVEILLANCE
Primary care providers are invited to enroll as sentinel providers for influenza surveillance in San Francisco. Compiling and reporting data usually takes less than 30 minutes per week. If interested in participating, contact the California Department of Public Health ator (510) 231-6861.
REMINDERS
SFDPH website influenza page: To report influenza deaths and/or cases or outbreaks as described above, call (415)554-2830. Within San Francisco, the public can call 311 for basic information about influenza.
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