Health Update
INFLUENZA VACCINATION - UPDATE

This is a general update from the Delaware Division of Public Health (DPH) on the influenza vaccine shortage situation in Delaware. Following this update is information from CDC regarding the use of antiviral medications for the treatment of influenza.

Influenza Illness

• DPH has initiated surveillance for influenza and influenza-like illness. Neither have been detected in Delaware as of this date.

Vaccine Availability

• On October 18, 2004 DPH began distribution of nearly 3000 doses of Delaware Vaccine for Children (VFC) vaccine to Delaware physicians. This is approximately one-third of the doses originally ordered by VFC participating physicians. DPH anticipates, based on current information, filling 100% of VFC orders over the next 6-8 weeks.
• DPH anticipates as much as 11,000 additional doses for the general, high risk public. However, there is no confirmation at this time of the number of doses or when it will be shipped to DPH. Therefore, clinics for the general, high risk public have not yet been scheduled.
• Aventis and CDC shipped 2 million does of vaccine nationally. The number of doses shipped to Delaware hospitals, long term care facilities and private providers is not known. This is the first shipment of up to 22.4 million doses of vaccine that will be distributed nationally.
• Providers caring for a large number of high risk patients are urged to inform their vaccine distributor of the nature of their patient population. DPH has been told that distributors are giving preference to health care facilities and practices serving such patients.

Advice to Patients

• Vaccine administration should be limited to people in high risk categories as described by CDC. Information about the high risk groups that is suitable for posting in a clinical office can be found at this website: http://www.cdc.gov/flu/professionals/flugallery/shortageflyers.htm
• In addition to vaccination, there are other ways to prevent the spread of influenza. Information about preventing flu suitable for posting in a clinical office can be found at this website: http://www.cdc.gov/flu/professionals/flugallery/shortageflyers.htm
• High risk patients should contact their primary care provider periodically to find out if the provider has received vaccine and listen to the news for the availability of public clinics. Generally, patients should not be directed to hospitals for vaccination.
• Live attenuated nasal-spray flu vaccine is an alternative to vaccination for most healthy children and adults between the ages of 5 and 49 years. DPH is aware that nasal-spray flu vaccine is available on a limited basis in Delaware. Information about nasal-spray flu vaccine can be found here:  http://www.cdc.gov/flu/professionals/vaccination/live.htm
• High risk patients should be urged to contact their primary care provider upon onset of influenza-like illness for consideration of antiviral therapy. When administered within 2 days of illness onset these medications can reduce the duration of uncomplicated influenza A and B.

For More Information

• DPH Immunization Hotline: 1-800-282-8672
• DPH Website: http://www.state.de.us/dhss/dph/
• CDC Website: http://www.cdc.gov/flu/
• National Immunization Hotline at (800) 232-2522 (English), (800) 232-0233 (Español), or (800) 243-7889 (TTY).

This is an official
CDC Health Advisory

Distributed via Health Alert Network
October 19, 2004, 16:45 EDT (04:45 PM EDT)
CDCHAN-00215-04-10-19-ADV-N

Influenza Antiviral Medications:
2004-05 Interim Chemoprophylaxis and Treatment Guidelines

Influenza antiviral medications are an important adjunct to influenza vaccine in the prevention and treatment of influenza. In the setting of the current vaccine shortage, CDC has developed interim recommendations on the use of antiviral medications for the 2004-05 influenza season. These interim recommendations are provided, in conjunction with previously issued recommendations on use of vaccine, to reduce the impact of influenza on persons at high risk for developing severe complications secondary to infection. The recommendations are not intended to guide the use of these medications in other situations, such as outbreaks of avian influenza. These interim recommendations may be updated as more information on the supply of influenza vaccine and antiviral medications becomes available.

Background

Influenza antiviral medications have long been used to limit the spread and impact of institutional influenza outbreaks. They also are used for treatment and chemoprophylaxis of persons in other settings. In the United States, four antiviral medications (amantadine, rimantadine, oseltamivir and zanamivir) are approved for treatment of influenza, though limited supplies of zanamivir are currently available. When used for treatment within the first two days of illness, all four antiviral medications are similarly effective in reducing the duration of illness by one or two days. Only three antiviral medications (amantadine, rimantadine and oseltamivir) are approved for chemoprophylaxis of influenza. More detailed information about each medication, including dosage and approved persons for use, may be found at: http://www.cdc.gov/flu/professionals/treatment

2004-05 Antiviral Medications Usage Guidelines

CDC is issuing interim recommendations for the use of antiviral medications during the 2004-05 season. Local availability of these medications may vary from community to community, which could impact how these medications should be used.

CDC encourages the use of amantadine or rimantadine for chemoprophylaxis and use of oseltamivir or zanamivir for treatment as supplies allow, in part to minimize the development of adamantane resistance among circulating influenza viruses.

People who are at high risk of serious complications from influenza may benefit most from antiviral medications. Therefore, in general, people who fall into these high risk groups should be given priority for use of influenza antiviral medications :

Treatment

• Any person experiencing a potentially life-threatening influenza-related illness should be treated with antiviral medications.
• Any person at high risk for serious complications of influenza and who is within the first 2 days of illness onset should be treated with antiviral medications. (Pregnant women should consult their primary provider regarding use of influenza antiviral medications.)
• Rimantadine is not approved for treatment of children aged < 13 years. For treatment, these persons should receive amantadine (children aged 1-12), oseltamivir (children aged 1-12), or zanamivir (children aged 7-12).

Chemoprophylaxis

• All persons who live or work in institutions caring for people at high risk of serious complications of influenza infection should be given antiviral medications in the event of an institutional outbreak. This includes nursing homes, hospitals, and other facilities caring for persons with immunosuppressive conditions, such as HIV/AIDS. When vaccine is available, vaccinated staff require chemoprophylaxis only for the 2-week period following vaccination. Vaccinated and unvaccinated residents should receive chemoprophylaxis for the duration of institutional outbreak activity. Rapid tests or other influenza tests should be used to confirm influenza as the cause of outbreaks as soon as possible. However, treatment and chemoprophylaxis should be initiated if influenza is strongly suspected and test results are not yet available. Other outbreak control efforts such as cohorting of infected persons, and the practice of respiratory hygiene and other measures also should be implemented. For further information on detection and control of influenza outbreaks in acute care facilities, see: http://www.cdc.gov/ncidod/hip/INFECT/flu_acute.htm
• All persons at high risk of serious influenza complications should be given antiviral medications if they are likely to be exposed to others infected with influenza. For example, when a high-risk person is part of a family or household in which someone else has been diagnosed with influenza, the exposed high-risk person should be given chemoprophylaxis for 7 days.

Antiviral medications can be considered in other situations when the available supply of such medications is locally adequate.

Chemoprophylaxis of persons in communities where influenza viruses are circulating, which typically lasts for 6-8 weeks:

• Persons at high risk of serious complications who are not able to get vaccinated.
• Persons at high risk of serious complications who have been vaccinated but have not had time to mount an immune response to the vaccine. In adults, chemoprophylaxis should occur for a period of 2 weeks after vaccination. In children aged <9 years, chemoprophylaxis should occur for 6 weeks after the first dose, or 2 weeks after the second dose, depending on whether the child is scheduled to receive one or two doses of vaccine.
• Persons with immunosuppressive conditions who are not expected to mount an adequate antibody response to influenza vaccine.
• Heath-care workers with direct patient care responsibilities who are not able to obtain vaccine.

Treatment of infected adults and children aged >1 year who do not have conditions placing them at high risk for serious complications secondary to influenza infection.

Where the supplies of both influenza vaccine and influenza antiviral medications may not be sufficient to meet demand, CDC does not recommend the use of influenza antiviral medications for chemoprophylaxis of non-high risk persons in the community.

Private Sector Sources of Influenza Antiviral Medications

Pharmaceutical distributors should be contacted directly for availability and procurement of antiviral medications.

Strategic National Stockpile

The United States has a limited supply of influenza antiviral medications stored in the Strategic National Stockpile for emergency situations. Efforts are underway by Health and Human Services to procure additional supplies of antiviral medications. Some of the supply will be held in reserve in the event of an influenza pandemic. However, some of the supply will be made available to States and Territories for use in outbreak settings, as might occur in a hospital or long term care facility.

Requesting Influenza Antiviral Medications from the SNS

Influenza antiviral medications in the SNS can be requested only by State or Territory Health Departments. Institutions (hospitals or long-term care facilities) experiencing an urgent need for such medications should convey their request to the State or Territory Health Department.

1. The State or Territory Health Department should call (770) 488-7100, the CDC 24/7 emergency number, to make a request for antiviral medications. A logistics plan is being drafted and will be available to all state and territorial health departments in the near future.
2. The State or Territory Health Department should indicate that there is an urgent priority use situation (as defined previously) that can be addressed by use of antiviral medications, and should indicate that all reasonable efforts have been made to procure influenza antiviral medications from private distributors.

For More Information

• CDC Website at: http:www.cdc.gov/flu
• National Immunization Hotline at (800) 232-2522 (English), (800) 232-0233 (Español), or (800) 243-7889 (TTY).