Weekly Report on Novel H1N1 Influenza (swine flu) as of June 18, 2009.

This Week’s Developments:
A very sad development this week was the announcement on Monday of the state's first H1N1-related death, a Boston resident in her thirties.  As of today, the CDC has reported 44 deaths and more than 17,000 confirmed cases of H1N1. 

Any death related to the flu is tragic, especially when it involves a young person.  While the vast majority of patients affected by H1N1 flu have recovered after mild illness, this death is a reminder of how serious any case of influenza can be for some people (see the list below for high risk populations).

Pregnant women are a group of people that are at higher risk of complications from the flu.  To underscore that fact, DPH today issued a clinical advisory reminding health care providers throughout the state to be especially vigilant in their diagnosis and treatment of pregnant patients.  The advisory stressed the importance of early treatment with antiviral therapy of pregnant women who seek care because of influenza-like illness.

Update on Massachusetts:
We continue to see person-to-person spread of the H1N1 flu virus here in Massachusetts, and the level of influenza activity in our state is still much higher than it normally is at this time of year.  

The CDC has reported that the New York and New England regions continue to see elevated influenza activity.  Visit CDC's FluView flu surveillance data to examine flu data from our region and other regions from around the country.  Massachusetts and the other New England states are in "Region I" and New York is in "Region II".   The CDC also reported that 89% of all influenza viruses being reported to the agency were novel H1N1. 

This new strain of virus is the predominant strain of flu that is circulating now and is likely the cause of an increase in visits to health care providers throughout Massachusetts.  Although the percentage of visits for influenza-like-illness to health care providers in our surveillance network increased last week, the rate of increase was less than the previous week. 

Data from the Boston Public Health Commission's surveillance systems indicate that the level of H1N1 influenza appears to be declining, however influenza-like-illness continues to be seen at levels well above what is normally seen this time of year.  BPHC's impressive disease surveillance system links all of the city's hospitals to the public health team at the Commission's Communicable Control Disease Division. Download BPHC H1N1Flu Update

Most schools in Massachusetts will be letting out this week or soon thereafter, and as of today only 2 schools in Boston are closed.  Both schools are scheduled to reopen on Friday.

With the end of the school year, focus on prevention activities at summer camps will be a high priority.  Earlier this month DPH issued guidance to both day and residential camps regarding preventing and managing H1N1 flu.  This week the CDC issued its guidance for camps. We will be updating our guidance to ensure consistency with CDC.  

Cases:

• There are now 1,273 confirmed cases of H1N1 flu in Massachusetts (120 more than our report last week).
• There have been 99 people hospitalized since the outbreak began (19 more than our last update).
• There has been 1 death since the outbreak began.

Age breakdown on confirmed cases:
0-4            190       
5-24          738        
25-64        331       
65+           13       
Unknown   1                

Flu outbreaks evolve in unpredictable ways; it is impossible to know whether this outbreak will decrease, remain the same, or grow in coming weeks, and whether the illness will remain at its current severity which, on the whole has been relatively mild for most people.

Some severe cases may occur in people with underlying risk factors such as young children, the elderly, and people with chronic medical conditions.

Guidance for the Public:
Preventing the Flu:  Because there is no vaccine for H1N1 influenza, public health officials remind all Massachusetts residents to continue taking simple steps to keep themselves and others healthy.

• Wash your hands frequently with soap and warm water or use an alcohol-based hand sanitizer.
• Cover your cough with a tissue or cough into your inner elbow and not into your hands.
• If you are sick stay home from work and if your child is sick keep them home from school for 7 days, or 24 hours after your symptoms go away—whichever is longer.
• Stay informed about the latest developments on the H1N1 flu.

Treating the Flu:  Most people that get the H1N1 flu do not need to be tested or seen by a doctor.  They can simply stay home, get plenty of rest, and take over-the-counter medication for their fever, aches and pains.  Although the H1N1 flu doesn’t seem to be more severe than the seasonal flu, certain groups of people may be at greater risk for complications from any flu – whether seasonal or H1N1. 

Anyone in the groups listed below who has a fever, along with a cough, sore throat or runny nose, should contact their doctor to talk with them about treatment with antivirals.  Antivirals work best if they are taken within 2 days of when symptoms start, so even people with mild illness should call their doctor right away if they have any of these conditions.

• Children less than 2 years old
• People age 65 years or older
• Pregnant women
• People who have chronic health problems like heart disease, asthma or diabetes
• Children and teens who are on long-term aspirin therapy who might be at risk for experiencing Reye’s syndrome after influenza virus infection
• Adults and children who have compromised immune systems caused by medications or by HIV infection

Comments

[Robyn]

My question is this are there guidelines that my workplace should be following? Are they allowed to insist that FMLA documentation to be filled out by my PCP to be out of work with H1N1 or should a doctors note be sufficient? What is the Public health Department doing to ensure that these company are not disciplining or firing employees for being out of work, when there is a no sick policy? Does my company need to notify the employees around me that someone has tested positive? There are many guidelines posted by both the cdc and public health department, so why are some companies choosing not to following them? Peolple are infected with this virus and there told to stay home, but they are also being threatened at the same time by there employer of being disciplined or terminated. What steps can an employee take to ensure that there company follows the CDC guidelines?

[Mahima]

Does a PCR test for Influenza A & C indicate whether one needs to go in for a Swine flu test?

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Thanks for your question. Confirmatory testing for H1N1 flu is now done on a very limited basis, usually to confirm the illness in only the sickest patients.

[Jane]

Hi, I was planning a trip from the end of June through July to visit north of Boston area (Lynn, Saugus, Salem, etc...). But since reading about your H1N1 situation, I am considering changing my holiday plans. My 14 year old son has mild CP and asthma. When he gets a respiratory infection, he sometimes has to take his rescue meds every 4-6 hours around the clock. Given my son's condition, would you advise me to avoid the MA area for the time being?

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Tom Lyons Responds: Hi Jane, thanks for your question. There are no travel advisories issued for any state that has had cases of novel H1N1 flu, including Massachusetts. However, you know best about your child’s condition and should make the decision to travel based on that knowledge. The question about whether to travel is less about where, than about how to protect yourself and your son no matter where you travel this summer -- novel H1N1 flu is circulating in all 50 states. Frequent hand-washing, practicing good cough etiquette, and avoiding people who are ill are important steps that everyone should be taking right now.

[Kelly Nocchi]

My question is this: I have been hearig rumors that they will be vaccinating kids for the swine flu in their schools come fall. Also that they will not be seeking parental consent before vaccinating all the school children. Is there any truth to this rumor? Thanks for your time.

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Hi Kelly, thanks for your question. This is a rumor. Vaccine for novel H1N1 has not yet been developed, however when it is -- as with all other childhood vaccines -- parental consent would be required prior to administration.

[Sara]

my teen son had fever, headache and sore throat yesterday morning (hx asthma too) so dr started tamiflu but also took a throat culture, and today it shows strep. Since we have an alternative diagnosis, assuming he responds to antibiotics, should he a)continue tamiflu b)stay out of school the full 7 days (last day is later this week)? what about risk of others of exposure to him (75 year old grandparents and 1 year old cousin plan to visit this weekend?)

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Tom Lyons Responds: Hi Sara, thanks for your question. The best person to talk about specific medical care or guidance regarding your son is his health care provider. Please check with your son's doctor on these questions. If he does have an alternative diagnosis, he does not fit into the definition of Influenza-like-Illness. The guidance that we give for school exclusion is for students who are exhibiting signs and symptoms of flu-like illness. As a general rule, those at the extremes of age (the very young and old) should not be exposed to someone who is ill, but again you should check with your son’s health care provider on this. In general, if a person has strep throat and takes the appropriate antibiotics they should not be infectious after being on the medication for at least 24 hours.

[William Green]

I'm wondering if you could point me to a peer reviewed study that actually shows hand washing and sneezing into your elbow are effective means of limiting the spread of influenza. Sounds like a lot of feel good baloney to me.

[Cheryl]

How soon before symptoms appear can you test positive for H1N1? Also, how long after symptoms have stopped will you test positive for H1N1?

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Suzanne Crowther Responds: Hi Cheryl- Thanks for your question. At this point we don’t know exactly how soon before symptoms appear or how long after they stop that someone would test positive for H1N1. CDC is doing studies now to answer these questions. Stay tuned!

[Jing Wang]

Hello,I am a teacher from China The Mainland. I will arrive Boston in 19th ,July,2009,and I will spent about two weeks there studying English.SO I am very worried about the situation of the H1N1 in local school.Which cases should I pay more attention to? Am I safety there for eating and shopping?
HIGHLY THANGKS

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Suzanne Crowther responds: At this point, there is likely to be H1N1 flu in every community in Massachusetts --whether in schools, restaurants or stores. But there are simple steps you can take to protect yourself. The most important step is to wash your hand frequently with soap and warm water, or use an alcohol-based hand sanitizer. You should also try to keep your hands away from your eyes, nose and mouth. That's how germs enter to body and make you sick. And lastly, try to avoid close contact with people that are coughing and sneezing.

[Rebecca Reed]

I brought my son to the pediatrician today for high fever & a back ache. I thought for sure it would be a UTI or something like that. Instead we were told that he has signs & symptoms consistent with the H1N1 influenza. We were also told that Massachusetts is no longer doing quick tests on patients with suspected cases of H1N1 and are instead only testing those who are experiencing difficulties with the flu. I don't understand this procedure, I don't understand not treating or even testing a 6 yr old boy with a history of recurrent pneumonia. I am beyond concerned with the lack of care and concern over this outbreak. It's very upsetting that we are not being informed of just how many cases there really are out there and even more upsetting that my son is potentially facing a life threatening disease that the state & our pediatricians aren't treating or even disclosing to the other parents.

[Sandra Carder]

We will be traveling through your state on route to a vacation destination. We are concerned about what additional precautions, if any, are being taken at rest stops along the major highways in the state. Can you provide that information? Are there more strict guidelines for cleaning facilities and/or public areas?

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Tom Lyons Responds: Hi Sandra, thanks for your question. We've not provided any additional guidelines for cleaning of facilities -- routine, normal cleaning is sufficient. The most important prevention measures that we can all take to avoid the flu is to wash our hands often with soap and warm water, and use alcohol-based hand sanitizer if soap and water is not available. Covering coughs and sneezes is also very important. Cough into a tissue and dispose of the tissue properly, or cough into your sleeve or inner elbow if tissues aren't available. Avoid coughing into your bare hands. Also, try to make it a habit not to touch your face, eyes or nose with your bare hands.

Enjoy your vacation.

[Dave]

Are schools required to notify parents if staff or students contract H1N1?

Are schools notified by state or local health officials about confirmed cases?
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Tom Lyons Responds: Hi Dave, thanks for your question. It's a local decision on how the school community is informed. However, most schools have informed students, staff and parents when they know of a confirmed case. Of course, at this point in the outbreak only the sickest patients in the state are likely to be tested for H1N1 flu, so if a student only has mild illness he/she will most likely not be tested. H1N1 flu has spread to every area of our state, so if there are students in your community who are out with Influenza-like Illness (fever with cough and sore throat or runny nose) there's a good chance they have novel H1N1 flu. The H1N1 strain is the predominant strain circulating in the nation and here in Massachusetts. Our state and New York are still seeing elevated influenza activity as compared to the rest of the country.

[Steffie]

I suppose it makes a difference in where the work in the home has to be done so I should mention it is in the bathroom/bedroom area and not sure how extensive it will be. I wouldn't be as concerned if it were the basement (where I also have a problem that needs kind of immediate attention too).

[Steffie]

I forgot to ask do you have any advice for the homeowner who needs necessary repairs inside their home. I am afraid to have them done as who knows if the repairman that comes has H1N1 at home or is coming down with it himself......Unfortunately, I have more than one that needs to be done ASAP.

With my luck they will get here and start working and also sneezing or coughing and one would be an all day job.

[Steffie]

Why is Boston singled out as being reported on as far as cases, ages, hospitalizations, etc. and not the rest of Massachusetts. Since I do not live in Boston or Suffolk county but in Middlesex county where there were many cases reported when the counties were listed how do I know the counts in my area. Also, I have a low grade fever, cough, stuffy nose and sore throat but from what I understand to have the H1N1 your fever would be higher so I figured it is just a virus. Doc is gone for the weekend now.......

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Tom Lyons Responds: Steffie, the report that we linked to in the post was provided by the Boston Public Health Commission, which operates its own surveillance system for the hospitals in the city. We thought people would be interested in seeing the advisory.

As we have said, the H1N1 flu has spread to every area of the state, so we should all assume the flu is circulating in our communities. The symptoms you describe sound like flu-like illness, but call your health care provider on Monday to discuss your condition. (You may also want to limit you exposure to others while you are feeling ill). We have resources on our web site if you are sick, or you think you are sick. You can find them at www.mass.gov/dph/swineflu.

Thanks for your comment and I hope you feel better soon.

[Rosalyn]

Regarding my previous post I wanted to add I have Crohn's disease and am allergice to all antibiotics but 2 so I am afraid ofcomplications from the flu, seasonal or otherwise. Are you aware if Aventis Pasteur is even making Fluzone Preservative free for seasonal flu as this year I am afraid they are concentrating on a swine flu vaccine......in which case I'll really be in trouble, esp. if they only make a regular swine flu vaccine also. Their antibiotic, preservative free vaccine has kept me well for the past years.

Thank you.

=======================

Tom Lyons Responds: Hi Rosalyn, please see my answer to your first comment below.

[Brian Davis]

What diffrence does it make if you stay home or go to the dr.
I have to stay home because I am not elegible for any form of heath insurance in this state because I am disabled and have medacare part A. and can not afford prt B and D

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Tom Lyons Responds: Brian, thanks for your comment. If you're looking for help finding health insurance, contact the Mass. Health Connector by going to its web site at http://www.mahealthconnector.org, or by calling 1-877-MA-ENROLL (1-877-623-6765).

[Rosalyn]

I don't understand - the one report says there are 13 cases 65+ and the table only lists 5. Being that I am over 70 and hubby is a bit younger (with asthma) and is still working I feel I am at a greater risk than those elderly who are retired. My immune system is not that good either and of late have had viral upper respiratory illnessess every few weeks - or it is the same one that keeps coming back. I have not been sleeping well for a few months and probably that is contributing to the frequent illnesses. I have a couple of chronic conditions also -- what are my chances with this swine flu if I should get it? My doc says he will only give me the Tamiflu if I test positive for H1N1 and it says a negative rapid flu test does not rule out a diagnosis of influenza.

I am also allergic to the "normal" flu shot. What are the chances of there being an antibiotic free, preservative free swine flu shot like the Fluzone preservative free with no antibiotics. It is the only flu shot I can take being allergic to neomycin and thimerasol.

Thank you.

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Tom Lyons Responds: Rosalyn, thanks for your comments. On the 65+ confirmed case numbers, I think you were looking at two sets of numbers the statewide number is (13) and the number in Boston is (5), which is listed in the advisory that we linked to.

As you have described your situation, your age alone places you in a group with a higher risk of complication should you get the flu. When talking to your health care provider, you should be sure that he/she has the latest treatment guidelines for H1N1. You can find those guidelines at the following web site:

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

The federal government is in the early phases of vaccine development for an H1N1 vaccine, so I don't have the answers to your questions with regard to that topic. I do expect we'll hear more about those plans in the coming weeks and we'll provide information as we get it.

[a]

It would be nice if the numbers were broken down a little more by age. 25-64 covers an awful lot of people. A breakdown of hospitalizations by decade of age and yes or no to underlying conditions, and a list of ALL types of condition considered "underlying" for these purposes. Mass. has done a good job compared to other states, but there is still a sense of trying downplay the situation

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Thanks for your comment. The age categories are the categories that we report to CDC. Your point is well taken and we'll try to provide greater granularity of the data in future updates.

[Joyce Lambert]

I am troubled by the removal of county specific reporting of confirmed H1N1 cases on this website. I can understand changing to a once a week reporting schedule but you have also removed the county location/component. This effectively eliminates my ability to make informed and preventative health related decisions for my family. As a Massachusetts taxpayer I would like to know where I can obtain this information now that it no longer available on the state site. Please post an alternate website, agency, etc. where the public may view this important information.

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Tom Lyons Responds: Ms. Lambert, thank you for your comment. We are no longer providing county-level data at this point in the outbreak. As we have indicated in our updates, novel H1N1 flu has spread to every county of the state at this point. Every resident of Massachusetts should follow the prevention guidelines that we have been communicating throughout the outbreak. At this point, county level data should have no impact on the actions that each of us take in trying to prevent infection. Again those steps are practicing good hand hygiene, covering coughs or sneezes with a tissue, or into one's sleeve or inner elbow and staying home from school or work if ill. The period of time that people should stay home if ill is 7 days, or 24 hours after symptoms resolve -- which ever is longer.

[Kathy]

This information is very misleading. Of course the number of confirmed cases is on the decline - because last week you made the decision to test only individuals in high risk categories. It's still out there; but doctors are following your guidance and telling people not to come into the office or the ER and just to stay home. I agree with that, but how can you make a statement that the numbers are declining? You actually have no way of knowing that since you have stopped testing to confirm cases.

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Tom Lyons Responds: Hi Kathy, I'm not sure what you find misleading, but our post does not say that confirmed cases have declined. In fact the information that we have provided showed an increase of 120 cases since last week. What you may be referring you is the advisory from the Boston Public Health Commission, which we write about in our update. That advisory reports that visits to ERs in the city for Influenza-like-illness appear to be declining. H1N1 flu is the predominant strain of flu circulating in Massachusetts right now. I provided a link in the post and you can download the report to look for yourself. Our statewide surveillance system shows ILI visits continued to increase but that the rate of increase was less than the week before.

Thanks for your comment.