Each Patient Counts: Massachusetts Medical Society Weblog

MMS Flu Advisory: DPH Updates Guidance on Flu Testing

The Massachusetts DPH on May 22 updated its guidance testing, treatment and phrophylaxis for the H1N1 (swine flu) virus. The full text of the guidance is below.

The total number of confirmed cases in Massachusetts is now 284. Seventy-eight percent are under the age of 21.

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This update is intended to clarify guidance on testing for the novel swine-origin influenza A (H1N1), and to limit the use of testing to those situations where they are most likely to be beneficial. This guidance also gives the website links to the latest antiviral diagnosis, management, treatment and prophylaxis guidelines.

Testing

CDC and Massachusetts Department of Public Health (MDPH) recommend that testing and treatment be focused on those with severe respiratory illness and those at highest risk of complications from influenza.   Individuals with mild illness should be advised to stay at home.  They do NOT need to be tested or treated unless they meet one of the high-risk criteria listed below.

Specimens should only be submitted to the Hinton State Laboratory Institute (HSLI) for testing for patients in the following situations:

• Those with flu-like febrile respiratory illness or sepsis-like syndrome requiring hospitalization
• Those at high risk of complications with influenza and who are exhibiting more serious signs of influenza like illness.  Such groups include:
  • Children < 2 years old
  • Persons > 65 years
  • Adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV);
  • Adults and children who have chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders;
  • Pregnant women;
  • Children and adolescents (less than 18 years) who are receiving long-term aspirin therapy who might be at risk for experiencing Reye syndrome after influenza virus infection;

New:

For individuals with asthma or other high risk conditions who are experiencing mild illness, a rapid influenza test may be performed.  If the result it positive, no further testing for novel influenza A (H1N1) is needed and appropriate treatment should be initiated.

Specimen Collection

Clinicians and laboratories should always contact an MDPH epidemiologist at 617-983-6800 (available 24/7) before submitting specimens. They will be able to assist in guidance for all issues regarding specimen collection and submission guidance, including assistance with transportation of specimens to the HSLI.  We will be posting our latest guidance about specimen collection and other recommendation on the MDPH website at www.mass.gov/dph/swineflu.

Clinical Management and Treatment

Adults and children with fever and one of the following: cough, sore throat or runny nose, should stay home from work or school for at least 7 days from the onset of illness (or 24 hours after the end of illness if symptoms persist longer).   They should not return to work or school before the end of the exclusion period even if asymptomatic because viral shedding can continue for 7 days. A health care provider’s note recommending a child return to school before the end of the full exclusion period does not supercede the public health guidance during this outbreak.  However, individuals who have recovered from influenza-like illness do not need to be “cleared” by a health care provider before returning to work or school after the end of their 7 day exclusion period. 

The latest information for clinicians on identifying and managing patients with influenza A H1N1 infection can be found at: http://www.cdc.gov/h1n1flu/identifyingpatients.htm

The latest information about antiviral treatment and prophylaxis, including new FDA emergency use authorization for the use of antivirals in children < 1 year and pregnant women, can be found at: http://www.cdc.gov/h1n1flu/recommendations.htm

Special Populations

The latest clinical guidance for treating the following special populations can be found on the CDC website:

• Pregnant women: http://www.cdc.gov/h1n1flu/clinician_pregnant.htm
• Infants and children: http://www.cdc.gov/h1n1flu/childr entreatment.htm.
• Individuals with cardiovascular disease: http://www.cdc.gov/h1n1flu/guidance/cardiovascular.htm
• Individuals with HIV/AIDS: http://www.cdc.gov/h1n1flu/guidance_HIV.htm

For additional information from CDC, please go to http://www.cdc.gov/h1n1flu/.

MMS Flu Advisory: Updated Guidance for Schools and Child Care Settings

As of 11:00 a.m. today, the Massachusetts Department of Public Health (MDPH) is reporting a total to date of 193 confirmed cases of H1N1 (swine flu). Charts produced by DPH reveal the majority (70%) of cases are occurring in patients aged 6 – 20 years old. Eight percent of cases have required hospitalizations. For details, see today’s updated case count report on the MDPH website.

Several schools across the state have had high rates of absenteeism due to influenza like illness. Yesterday, the Massachusetts Department of Public Health (MDPH) provided updated guidance for schools and child care settings. Guidance may continue to change in the upcoming weeks as the situation changes, and as more information becomes available. 

The updated May 19 guidance document is available on the DPH website, and is copied below:

The guidance document provides information in three categories:

• Surveillance and Prevention Measures for ALL Schools and Child Care Facilities
• Enhanced Surveillance and Prevention Measures for Schools with Cases of Influenza-like Illness (ILI)
• Factors to Consider with Regard to School Closings

Recommendations for Surveillance and Prevention of Swine-Origin Influenza A H1N1 in Massachusetts Schools and Child Care Settings

The following recommendations apply to all schools in the Commonwealth, regardless of whether or not they are experiencing higher than usual rates of absenteeism. They are designed to help prevent the spread of ILI in school and child-care settings.

• Emphasize to students and parents, the importance of proper hand washing and cough etiquette in preventing the spread of diseases. Educational materials, posters, etc. are available on the MDPH website, www.mass.gov/dph/swineflu.
• Inform parents and caregivers that they should assess all family members (and especially all school-age children) for symptoms of influenza before sending them to school.  ILI may include fever plus cough, sore throat or runny nose.  It may also include other symptoms, such as vomiting or diarrhea. A Flu Symptoms Checklist is on the DPH website at www.mass.govdph/swineflu.
• All school staff should assess themselves for symptoms of influenza before reporting to work, and should stay home if they are symptomatic.
• Schools should consider screening students and staff for visible signs of possible influenza illness upon arrival at school.
• Students or staff who appear ill with influenza-like illness should be promptly isolated and sent home.  All such students and staff should stay out of school for at least 7 days even if their symptoms resolve sooner. Students and faculty who are still sick at 7 days should continue to stay home from school until at least 24 hours after they have completely recovered.
• If a child or adult is ill with other symptoms, they should stay home at least one day to observe how the illness develops and until completely well for 24 hours.  This period of exclusion can be shortened if it is found that the child is unlikely to have influenza, for example if an alternative diagnosis, such as strep throat, is made.
• School nurses and student health centers should report higher than normal absenteeism to your local health department or to the MDPH at 617-983-6800.

Recommendations for Enhanced Surveillance and Prevention of Swine-Origin Influenza A H1N1 in Massachusetts Schools and Child Care Settings

If cases of influenza-like illness are identified, schools/child care facilities should consider increasing their surveillance and infection control measures to limit the further spread of illness in their facilities.  These measures are enhancements of what schools/child care facilities do during flu season to prevent illness in children and staff.

Because CDC and MDPH recommend testing only those who are seriously ill, or who have underlying conditions which put them at increased risk for complications from influenza for H1N1, schools should consider implementing these enhanced measures when they see an increase in absenteeism due to influenza-like illness. They do not need to await confirmation of H1N1.

• Monitor absenteeism in students and staff and follow up to determine if absence is due to influenza-like illness. School nurses and student health centers should report higher than normal absenteeism to your local health department and to the MDPH Epidemiology Program at 617-983-6800.
• Screen students and staff as they enter school, during home room, or other appropriate times to identify anyone with fever and symptoms of influenza-like illness.  Any child that appears to have ILI should be isolated and sent home.  If the ill student or staff member has a cough, as well as fever, he/she should wear a mask (if available) until leaving the school to decrease the spread of the virus.If there are an unexpected number of absences in a particular class room or grade, screen the children in that class or grade to identify any that may have symptoms of ILI.
• Place hand sanitizer in each classroom to facilitate regular hand hygiene.  Encourage younger students to use the sanitizer before snacks and lunch.  Encourage older students that change classrooms to use hand sanitizer each time they change classes.
• Ask teachers or school nurses to demonstrate proper hand washing and cough etiquette in each class, and to explain why it’s important.  Educational materials, posters, etc., are available on the MDPH website, www.mass.gov/dph/swineflu.
• Send hand washing or other flu control educational materials home to parents and ask for their assistance in reinforcing these messages with their children.
• Distribute the Flu Symptom Checklist to families and ask that parents use it if they are unsure if their child is well enough to go to school.
• Consider increasing routine cleaning of classroom surfaces likely to be touched.  This should be considered only as an adjunct to the efforts to increase hand washing, improve cough etiquette and keep ill children and staff home, because cleaned surfaces can easily become re-contaminated during the day.

Preparedness Planning: Schools and childcare facilities should prepare for the possibility of school or childcare facility closure before facing this decision.  This includes asking teachers, parents, and officials in charge of critical school-associated programs (such as meal services) to make contingency plans.

Parent and Staff Reassurance

Parents, faculty and staff may need to be reassured that the school/child care facility is taking appropriate steps to limit the spread of illness.

Concerned parents, faculty and staff can be reminded that illness caused by swine-origin influenza A H1N1 is similar to that caused by seasonal flu, so our responses should be what they would be for seasonal flu.

Influenza is highly likely to be in the school or community, whether or not there is a confirmed case.    Parents and staff should assume that they could be exposed to this new flu at school, at work or anywhere else in the community.  Therefore, it is very important for everyone to continue to protect themselves with hand washing, cough etiquette, etc.

Special Populations

Some children or staff may be at greater risk for complications from any flu – seasonal or swine.  These include:

• Children less than 2 years old
• Persons aged 65 years or older
• Pregnant women
• Children and adolescents (less than 18 years) who are receiving long-term aspirin therapy who might be at risk for experiencing Reye’s syndrome after influenza virus infectionAdults and children who have chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders
• Adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV infection)

Staff or parents of children who fit any of the above criteria should discuss their specific situation with their doctor, just as they do when regular flu season starts.

Source: Massachusetts Department of Public Health (May 20, 2009)

MMS House of Delegates Addresses Payment Reform, Primary Care and Public Health

The MMS House of Delegates completed its work Friday afternoon and approved dozens of resolutions relating to payment reform, the primary care workforce, retail health clinics, and many public health issues.

Read a news release on the House's votes.

MMS Flu Advisory: May 8, 2009

Friday morning the Mass. Department of Public Health confirmed 12 additional cases in Massachusetts, which brings the total case count to 83.  Each of the new cases is expected to fully recover and 2 of the newly confirmed cases were hospitalized but has been discharged.

The next update on confirmed cases in Massachusetts will take place on Monday, May 11, 2009, at 11:00 a.m.

For more information on H1N1 flu (swine flu) please visit www.mass.gov/dph. 

Download Confirmed Cases as of 5-8-09

Payment Reform Commission Posits Framework for Shift to Global Payment

A framework for making an effective and orderly transition to global payment was the main topic at today’s next-to-last meeting of the Special Commission on the Health Care Payment System.

The commission’s transition framework relies heavily on the creation of Accountable Care Organizations (ACOs), virtual or actual provider networks that integrate health care services and improve coordination of patient care.

The structure, scope, and function of ACOs was one of many parameters that an independent board to oversee the transition would be charged with, according to the framework. The board would also be responsible for identifying adjustment factors for global payments and tracking milestones, among other tasks. The framework calls for board intervention if certain milestones are not met, which sparked debate about state rate setting and the stick-or-carrot approach to incentives. Commission member Alice Coombs, M.D., MMS president-elect, called for a “nurturing” approach to help providers make the change rather than penalty-based incentives.

The timeframe set forth in the framework for a completed transition to global payment is five years or less, and it encourages providers who are in a higher state of readiness to move more quickly.

There was also debate about the so-called “complementary strategies” that many stakeholders say must be addressed in tandem with payment reform. These include malpractice reform, health plan benefit redesign, and administrative simplification. Some commission members, including Dr. Coombs, insisted that these strategies are inextricably linked to payment reform, while other commission members said such matters could distract the board from its primary purpose.

The commission’s final meeting, originally scheduled for May 26, has been postponed until late June. Between now and then, the commission will iteratively draft a final report of recommendations for the Legislature.

To view the slides from today’s meeting, visit the Payment Commission’s website.

New England Journal of Medicine Releases New Research; Mass. Confirms 26 New Cases

The New England Journal of Medicine today published a comprehensive online-only package of research articles and commentary on the H1N1 (swine) flu virus.

They can be found at http://h1n1.nejm.org/

The articles are:

Original Article: Emergence of a Novel Swine-Origin Influenza A (H1N1) Virus in Humans
Fatima S. Dawood, Centers for Disease Control and Prevention, Atlanta, GA

Original Article: Human Infections with Triple-Reassortant Swine Influenza A (H1) Viruses in the United States, 2005-2009
Vivek Shinde, M.D., M.P.H., Centers for Disease Control and Prevention, Atlanta, GA

Editorial: H1N1 Influenza A Disease — Information for Health Professionals
Lindsey R. Baden, M.D., the New England Journal of Medicine, Boston, MA

Editorial: Implications of the Emergence of a Novel H1 Influenza Virus 
Robert B. Belshe, M.D., St. Louis University, St. Louis, MO

Perspective: The Signature Features of Influenza Pandemics - Implications for Policy
Mark A. Miller, M.D., National Institutes of Health, Bethesda, MD

Perspective: Digital Disease Detection - Harnessing the Web for Public Health Surveillance
John S. Brownstein, Ph.D., Children’s Hospital, Boston, MA

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Separately, the Mass. Department of Public Health announced this morning the confirmation of 26 new cases of H1N1 in Massachusetts, bringing the state’s total to 71.

DPH noted on its blog, "The increase in cases in Massachusetts, similar to what is being seen in other states, was expected given the intensity of surveillance for new cases, and the broad testing program for specimens early in the outbreak. DPH’s testing strategy, consistent with CDC guidelines, will change over time to focus on more seriously ill patients."

MMS Annual Meeting Opens With a Commitment to Physician Leadership

Bruce S. Auerbach, MD, president of the Massachusetts Medical Society, opened the Society's 2009 Annual Meeting this morning with remarks calling on physicians and the medical society to help lead health reform efforts.

The current environment "requires our willingness, as a profession and as a medical society, to change. We cannot advocate for the status quo, and expect to be taken seriously," he said.

Dr. Auerbach noted the work of the state Payment Reform Commission, which is studying new payment models for promoting efficient, effective and accessible health care. He praised the commission for appreciating the complexity of the problem and for "proceeding with due care."

He said that a new payment model could be a significant improvement over the current health care delivery system, providing that several conditions are in place:

• Spending levels must be sustainable and affordable for the society at large
• Payment levels for health care providers must be realistic
• All providers must have the tools to succeed under a new payment system. "If you're in a small practice," he said, "you have as much a right to thrive in a new system as the big teaching hospital. But you will need help, and you will need time to get that help."

"The good news is that everyone wants us to be at the table," Auerbach said, "and we have responded to that challenge. In truth, we have only one choice. We must lead."

The Society's House of Delegates is reviewing 46 resolutions that seek to establish MMS policies and programs in the areas of advocacy, education and Society administration. Today, reference committes heard testimony on the proposals. Tomorrow, the full House will vote on them.

MMS Flu Advisory: May 6, 2009

The Massachusetts Department of Public Health (MDPH) is now performing confirmatory testing for H1N1 influenza at the Hinton State Laboratory Institute.

The lab estimates that it will take between 24-36 hours to confirm samples submitted for testing. Beginning today, MDPH will begin updating the Massachusetts H1N1 case counts at 11 a.m. for the previous day’s confirmatory results. This schedule will allow DPH staff to make all the necessary notifications as part of their public health case investigation.  In addition, it will be consistent with current CDC policy to update the national case counts at 11 a.m. each day. Data includes the date of confirmation, the county where the case is located, and whether or not the case is hospitalized. Updated Case Counts are available on the MDPH website, www.mass.gov/dph/swineflu.

As of 11:00 a.m. today, MDPH is reporting 45 total cases, including 11 confirmed yesterday, May 5. A chart with age breakdown is posted below the case listing.

CDC Revises Guidelines on School Closures

The CDC today revised its initial recommendations on school closures.

"School closure is not advised for a suspected or confirmed case of novel influenza A (H1N1)," the CDC now says. "In general, [closing a school] not advised unless there is a magnitude of faculty or student absenteeism that interferes with the school’s ability to function."

It noted, "The primary means to reduce spread of influenza in schools focus on early identification of ill students and staff, staying home when ill, and good cough and hand hygiene etiquette."

Read the full text of the recommendation here.

With New Testing Capabilities, Massachusetts Confirms 28 New Cases of H1N1

The Massachusetts Department of Public Health tonight announced that it has confirmed 28 new cases of the H1N1 (swine) flu, bringing the total confirmed cases in the state to 34. In keeping with patterns nationwide, half of the cases were in patients under age 18.

The large increase announced tonight was anticipated. Previously, all suspected cases of H1N1 had to be sent to the CDC in Atlanta for testing. This resulted in a large backlog of suspected cases, which the state cleared up today after getting approval to do H1N1 tests on suspected cases at its labs in Boston.

State officials said none of the new cases are hospitalized and all are expected to recover. The cases in Massachusetts so far have been moderate in severity.

Following is a table of new and previously confirmed cases in Massachusetts.

Date Confirmed	Age*	County*	Symptom 0nset	Hospitalized (Y/N/U)
Wednesday, April 29, 2009	13	Middlesex	4/22/2009	N
Wednesday, April 29, 2009	9	Middlesex	4/26/2009	N
Friday, May 1, 2009	14	Middlesex	4/22/2009	Y (discharged)
Friday, May 1, 2009	47	Middlesex	4/26/2009	N
Friday, May 1, 2009	9	Middlesex	4/25/2009	Y (discharged)
Friday, May 1, 2009	33	Plymouth	4/25/2009	N
Monday, May 4, 2009	28	Bristol	4/29/2009	N
Monday, May 4, 2009	19	Hampshire	4/26/2009	N
Monday, May 4, 2009	20	Hampshire	4/28/2009	N
Monday, May 4, 2009	16	Middlesex	4/27/2009	N
Monday, May 4, 2009	47	Middlesex	4/24/2009	N
Monday, May 4, 2009	2	Middlesex	4/27/2009	N
Monday, May 4, 2009	37	Middlesex	4/27/2009	N
Monday, May 4, 2009	3	Middlesex	4/26/2009	N
Monday, May 4, 2009	14	Middlesex	4/27/2009	N
Monday, May 4, 2009	4	Middlesex		Y (discharged)
Monday, May 4, 2009	37	Middlesex	4/28/2009	N
Monday, May 4, 2009	17	Middlesex		N
Monday, May 4, 2009	47	Middlesex	4/25/2009	N
Monday, May 4, 2009	32	Middlesex	4/28/2009	N
Monday, May 4, 2009	7	Middlesex		N
Monday, May 4, 2009	31	Middlesex		N
Monday, May 4, 2009	12	Middlesex	4/27/2009	N
Monday, May 4, 2009	10	Middlesex	4/30/2009	N
Monday, May 4, 2009	17	Middlesex		N
Monday, May 4, 2009	16	Middlesex	4/25/2029	N
Monday, May 4, 2009	8	Middlesex	4/30/2009	N
Monday, May 4, 2009	17	Norfolk	4/27/2009	N
Monday, May 4, 2009	57	Norfolk	4/25/2009	N
Monday, May 4, 2009	7	Norfolk	4/19/2009	N
Monday, May 4, 2009	20	Plymouth	4/24/2009	N
Monday, May 4, 2009	24	Suffolk	4/26/2009	N
Monday, May 4, 2009	25	Suffolk	4/25/2009	N
Monday, May 4, 2009	26	Suffolk	4/27/2009	N

Earlier today, the state began distributing federal stock of antiviral medications and masks to hospitals. By the end of the week, the state's allocation of supplies will have been distributed to hospitals, emergency medical providers, and clinics at colleges and universities.