FW: Centers for Disease Control and Prevention (CDC) ALL CHET PARTNERS Update: revised antiviral use guidelines Q and A

[Guest guest]

Dear

Colleagues,

Here

is today’s email from CDC regarding guidelines for clinicians for use of

antiviral drugs. Please pass this information along to your clinician

colleagues as this list tends to be more oriented to administration and

research professionals.

Bobbi

Bobbi Ryder

President & CEO

National Center for Farmworker Health, Inc.

1770 FM 967

Buda, TX

(512) 312-5453 direct line

(512) 312-5451 Mendoza , Assistant

(512) 312-2600

www.ncfh.org

From: Centers for Disease

Control & Prevention [mailto:cdc@...]

Sent: Wednesday, September 09, 2009 7:46 AM

ryder@...

Subject: Centers for Disease Control and Prevention (CDC) ALL CHET

PARTNERS Update: revised antiviral use guidelines Q and A

DEPARTMENT

OF HEALTH & HUMAN

SERVICES Public

Health Service

Centers

for Disease Control

And

Prevention (CDC)

Atlanta, GA

30333

You

are signed up to receive updates from CDC's Community Health Outreach &

Education Team (CHET). CHET is part of CDC’s Emergency

Communication System – an all-hazards response unit with resources and

structures to provide emergency information through appropriate channels to

multiple audiences across the country.

Please read

the important public health information below and send to your constituency as

you see fit.

Questions & Answers

Revised Recommendations for the Use of Influenza

Antiviral Drugs

Background

On

September 8, 2009 CDC updated its recommendations for the use of influenza

antiviral medicines to provide additional guidance for clinicians in

prescribing antiviral medicines for treatment and prevention (chemoprophylaxis)

of influenza during the upcoming 2009-2010 flu season. These recommendations

are intended to help clinicians prioritize use of antiviral drugs for treatment

and prevention of influenza. In general, the priority for the use of antiviral

medications this season continues to be in persons at increased risk of

influenza-related complications as outlined in the antiviral recommendations

posted on May 6, 2009.

How is the new guidance different from the guidance that was

issued on May 6, 2009?

The

priority use for antiviral medications during the upcoming influenza season

remains the same as outlined in the antiviral recommendations posted on May 6,

2009; that is to prioritize use of these drugs for those patients who are

severely ill (hospitalized) and those patients who are ill with influenza-like

illness and who are at high risk for influenza related complications. The

updated guidance provides additional context and guidance for clinicians in an

effort to ensure that antiviral drugs are prescribed appropriately this season

and that they reach those in greatest need quickly. This includes actions that

clinicians may consider taking to reduce possible delays between illness onset

in high risk patients and treatment, including a suggestion that clinicians

consider providing prescriptions for antiviral medications ahead of time for

such patients. In addition, the updated guidance provides more information

about the appropriate (and limited) situations in which antiviral medications

should be used for chemoprophylaxis (prevention) this season. The updated

guidance states that antiviral drugs should not be used for prevention in

healthy persons based on community exposures. In addition, the guidance places

an emphasis on the use of antiviral drugs for early treatment (versus

preventatively). The updated recommendations seek a balance between providing

clinicians the information and guidance needed to reach those at greatest risk

with appropriate and timely treatment; to reduce the chances of

antiviral-resistance through inappropriate or unnecessary chemoprophylaxis; and

yet to still recognize the overarching importance of clinical judgment in

making treatment and chemoprophylaxis decisions.

What are influenza antiviral drugs?

Influenza antiviral drugs are prescription drugs (pills, liquid,

or inhaler) that decrease the ability of flu viruses to reproduce. While

getting a flu vaccine each year is the first and most important step in

protecting against flu, antiviral drugs are a second line of defense in the

prevention and treatment of flu.

Who is prioritized for treatment with

influenza antiviral drugs?

Most people ill with influenza will recover without

complications.

Some people are at increased risk of influenza complications and

are prioritized for treatment with influenza antiviral drugs this season. They

include:

·

People hospitalized with suspected or confirmed influenza

·

People with suspected or confirmed influenza who are at higher

risk for complications

o

Children younger than 5 years old (children under 2 years old are

at higher risk for complications than older children)

o

Adults 65 years and older

o

Pregnant women

o

People with certain chronic medical or immunosuppressive

conditions

·

People younger than 19 years of age who are receiving long-term

aspirin therapy

Physicians may also decide not to treat some people in these

groups and/or treat people who are not in these groups based on their clinical

judgment.

Who is lower priority for treatment with

influenza antiviral drugs?

Treatment with influenza antiviral drugs is generally not needed

for people who are not at higher risk for complications or do not have severe

influenza, such as those requiring hospitalization. However, any suspected

influenza patient who presents with emergency warning signs (for example,

difficulty breathing or shortness of breath) or signs of lower respiratory

tract illness should promptly receive antiviral therapy. Doctors may treat some

people who are not in a high risk group based on their clinical judgment. In

addition, doctors also may decide that treatment is not needed for some who are

in a high risk group based on their clinical judgment.

Which influenza antiviral drugs should be used for treatment this

season?

At this time, treatment with oseltamivir (trade name Tamiflu®)

or zanamivir (trade name Relenza®) is recommended for all people with

suspected or confirmed influenza who require hospitalization.

What are the treatment benefits of influenza

antiviral drugs?

For treatment, antiviral drugs should be started within 2 days

after becoming sick. When used this way, these drugs can reduce the severity of

flu symptoms and shorten the time you are sick by 1 or 2 days. They may also

prevent serious flu complications. Antiviral drugs may be especially important

for people who are very sick (hospitalized) or people who are sick with the flu

and who are at increased risk of serious flu complications, such as pregnant

women, young children and those with chronic health conditions.

How effective are antiviral drugs at

preventing the flu?

When used to prevent the flu, antiviral drugs are about 70% to 90%

effective against susceptible viruses (i.e., viruses that are not resistant to

the antiviral medication). It’s important to remember that flu antiviral

drugs are not a substitute for getting a flu vaccine.

When should health care providers start treatment with antiviral

drugs?

Once the decision to administer antiviral treatment is made,

treatment with zanamivir or oseltamivir should be initiated as soon as possible

after the onset of symptoms. Evidence for benefits from antiviral treatment in

studies of seasonal influenza is strongest when treatment is started within 48

hours of illness onset. However, some studies of oseltamivir treatment of

hospitalized patients with seasonal influenza have indicated benefit, including

reductions in mortality or duration of hospitalization even for patients whose

treatment was started more than 48 hours after illness onset. When

treatment is indicated, health care providers generally

should not wait for laboratory confirmation of influenza to begin treatment

with antiviral drugs because laboratory testing can delay treatment and because

a negative rapid test for influenza does not rule out influenza. The

sensitivity of rapid influenza diagnostic tests can range from 10-70% for 2009

H1N1 virus.

What can health care providers do to reduce delays in antiviral

treatment?

Clinicians can take several actions to reduce delays in antiviral

treatment initiation. These include:

1) Informing

people at higher risk for influenza complications of the signs and symptoms of

influenza and the need for them to get treated early.

2) Ensuring

quick access to telephone consultation and clinical evaluation for these

patients as well as patients who report severe illness.

3) Considering

empiric treatment of patients at higher risk for influenza complications based

on telephone contact if hospitalization is not indicated and if this will

substantially reduce delay before treatment is initiated.

What are the symptoms of seasonal influenza or 2009 H1N1

influenza?

The symptoms of seasonal and 2009 H1N1 influenza include fever,

cough, sore throat, runny or stuffy nose, body aches, headache, chills and

fatigue. Some people may also have vomiting and diarrhea. Some people may be

infected with the flu, including 2009 H1N1, and have respiratory symptoms

without a fever.

Who is at higher risk of influenza related complications?

Groups at higher risk for influenza related complications are

similar to those at higher risk for seasonal influenza complications and

include: children younger than 5 years old; adults 65 years of age and older,

pregnant women, people of any age with certain chronic medical conditions (for

example, asthma, diabetes, lung disease, people with weakened immune systems,

etc.) and people younger than 19 years of age who are receiving long-term

aspirin therapy.

For children younger than 5 years of age, note that the risk for

severe complications from seasonal influenza is highest among children younger

than 2 years old.

What actions should health care providers take when waiting for

influenza test results?

When treatment is indicated, health care providers should consider

empiric treatment while influenza test results are pending, if the clinicians

decided to test, especially if there will be a significant delay before testing

can be performed. Once the decision to administer antiviral treatment is made,

treatment with oseltamivir or zanamivir should be initiated as soon as possible

after the onset of symptoms.

How long should patients receive treatment with antiviral drugs?

The recommended duration of treatment is five days. However,

hospitalized patients with severe infections might require longer treatment

courses.

When should clinicians prescribe antiviral drugs for prevention of

influenza?

Pre-exposure antiviral chemoprophylaxis should only be used in limited

circumstances, and in consultation with local medical or public health

authorities. Certain people at ongoing occupational risk for exposure (health

care personnel, public health workers, or first responders who are working in

communities with influenza A H1N1 outbreak), especially those at higher risk

for complications of influenza, should carefully follow guidelines for

appropriate personal protective equipment to prevent influenza exposure to

influenza. Health care workers at high risk of influenza-related complications

who cannot minimize exposure may consider temporary reassignment.

Who should receive antiviral drugs for prevention of influenza?

Antiviral chemoprophylaxis generally should be reserved for people

at higher risk for influenza-related complications who have had contact with

someone likely to have been infected with influenza. As an alternative to

chemoprophylaxis, clinicians can also choose to counsel people at higher risk

for influenza-related complications about the early signs and symptoms of

influenza and advise them to immediately contact a health care provider for

evaluation and possible early treatment if clinical signs or symptoms develop.

Post-exposure antiviral chemoprophylaxis with either oseltamivir

or zanamivir can be considered for health care personnel, public health

workers, or first responders who have had a recognized, unprotected close

contact exposure to a person with confirmed, probable, or suspected 2009 H1N1

or seasonal influenza during that person’s infectious period. However,

use of recommended PPE and other administrative controls (e.g. having health

care personnel stay home from work when ill, and triaging for identification of

potentially infectious patients) should be used to reduce the need for post-exposure

chemoprophylaxis among health care workers. As an alternative to

chemoprophylaxis, health care personnel who have occupational exposures, can

also be counseled about the early signs and symptoms of influenza, and advised

to immediately contact their healthcare provider for evaluation and possible

early treatment if clinical signs or symptoms develop.

Should antiviral agents be used for post exposure chemoprophylaxis

in healthy individuals?

Antiviral agents are discouraged for prevention of illness in

healthy children or adults based on potential exposure in community, school,

camp or other settings. In addition, there are no safety data regarding long

term or frequent use of antiviral agents in children, and limited data for

healthy adults.

Which antiviral drugs should health care providers prescribe for

chemophrophylaxis of 2009 H1N1?

For antiviral chemoprophylaxis of 2009 H1N1 influenza virus

infection, either oseltamivir or zanamivir are recommended. Currently,

circulating 2009 H1N1 viruses are susceptible to oseltamivir and zanamivir, but

resistant to amantadine

What is the recommended duration for antiviral chemoprophylaxis if

used following exposure to someone with influenza?

Duration

of antiviral chemoprophylaxis post-exposure is 10 days after the last

known exposure.

What is the treatment of choice for pregnant women with suspected

or confirmed 2009 H1N1 infection?

Oseltamivir and zanamivir are " Pregnancy Category C”

medications, indicating that no clinical studies have been conducted to assess

the safety of these medications for pregnant women. Pregnancy should not be

considered a contraindication to oseltamivir or zanamivir use. Because of its

systemic activity, oseltamivir is preferred for treatment of pregnant women.

What side effects can occur with influenza antiviral drugs?

Side effects differ for each drug. If an antiviral drug has been

prescribed for you, ask your doctor to explain how to use the drug and any

possible side effects. Health care professionals prescribing flu antiviral

drugs should alert patients about adverse events that can occur. For more

information about side effects, see Antiviral Drugs: Summary of Side Effects.

Can antiviral drugs be helpful for people unable to take the flu

vaccine?

Yes. CDC and ACIP recommend use of antiviral drugs for people

allergic to eggs (which can cause them to have an allergic reaction to the

vaccine) or for people who previously have encountered complications from

Guillain-Barre syndrome (GBS) associated with influenza vaccination. In

addition, taking antiviral drugs may be recommended among persons that may not

have a good immune response to the flu vaccine.

Should people use antiviral drugs before or after receiving the

live attenuated influenza vaccine (LAIV) called FluMist®?

LAIV is one of two types of flu vaccine. It is given as a nasal

spray and contains weakened, live virus. Flu antiviral drugs taken from 48

hours before through 2 weeks after getting LAIV can lower or prevent the

vaccinated person from responding to the vaccine and the person may not get

immune protection from the vaccine.

Antiviral drugs can be taken with the inactivated (i.e. killed)

flu vaccine.

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