2009 New York City Department of Health and Mental
(NYC DOHMH) Health Alert #14: Swine Influenza Update
April 29, 2009
PLEASE NOTE: This is a rapidly evolving situation. This
alert provides interim guidance. It is possible that evidence
of community transmission of Swine-Origin Influenza A (H1N1)
(S-OIV) will emerge in the next few days. If and when community
transmission is established, and as more information is
available, this guidance will change.
Refer to Health Alert # 13 for current reporting
requirements, laboratory diagnostic testing guidance, and
infection control, antiviral treatment and prophylaxis
New developments since Health Alert # 13
New York City Epidemiologic Update
• Diagnostic testing at the Centers for Disease Control and
Prevention (CDC) has now confirmed 49 cases of Swine-Origin
Influenza A (H1N1) (S-OIV) in New York City residents. All
confirmed cases to date are epidemiologically linked to the
outbreak among students and staff at the St. Francis
Preparatory High School in Queens (n=47) or have an
epidemiologic link to Mexico (n=2). Seven probable cases are
currently under investigation.
o A probable case in Suffolk County does not have any known
links to the St. Francis outbreak or Mexico suggesting likely
exposure in a community setting.
o To date, illness in the United States and in New York City
continues to be no more severe than usual seasonal influenza,
with the overwhelming majority of diagnosed patients having had
o The DOHMH is conducting active surveillance for severe
febrile unexplained respiratory illness in all NYC hospitals,
and to date has identified only two patients who have been
hospitalized in New York City with probable or confirmed swine
influenza. One of these patients has been discharged and the
other is improving.
o DOHMH investigation of the S-OIV outbreak at St. Francis
Preparatory High School:
o Among the 47 confirmed cases epidemiologically linked to St.
Francis Preparatory High School, 44 have been interviewed. The
median age w as 16 years (range 15-22). The most frequently
reported symptoms included cough (43, 98%), subjective fever
(41, 93%), fatigue (39, 89%), headache (37, 84%), chills (36,
82%), sore throat (36, 82%), runny nose (35, 80%), and muscle
aches (35 (80%). Nausea, diarrhea, abdominal pain, shortness of
breath and joint pain were also reported, but less frequently.
At the time of the interview 37 (84%) reported that their
symptoms were stable or improving and 4 (9%) reported complete
resolution of symptoms. Only one reported having been
hospitalized briefly, for syncope.
o An on-line survey of all students (N=2686) and staff (N=228)
at the school is ongoing. Preliminary results from the on-line
school survey and passive surveillance indicate widespread mild
illness with hundreds of students and many staff reporting
symptoms which meet the case definition for ILI with illness
onset peaking on April 23rd and declining sharply thereafter.
Secondary transmission to household con tacts was reported in
approximately 8% of households responding to the survey.
o Given the evolving epidemiology of this outbreak in NYC and
elsewhere, the number of NYC cases is expected to increase in
the coming days and it is likely we will start to see evidence
of community transmission in NYC unrelated to the high school
outbreak. Updated case numbers and guidance will be issued in
• Routine NYC emergency department syndromic surveillance
shows that fever and influenza-related emergency room visits
began to increase on April 25, 2009, have increased on a daily
basis, and have been higher than in past seasons. The increase
is most dramatic among persons aged 18-59 years. It is unknown
at this time whether the increase is due to changes in
care-seeking behavior among persons with influenza-like illness
or to an actual increase in influenza-like illness in the
US and Global Epidemiologic Update
• As of 3 pm on 4/29/2009, 9 1 cases have been confirmed in 14
states across the US, including one death in a 23 month old
Texas child with an underlying high risk medical condition.
• Confirmed cases of S-OIV have been reported from an
increasing number of countries across the globe. Today the
World Health Organization (WHO) elevated the pandemic influenza
alert level to 5, indicating that widespread human infection is
occurring and a pandemic is imminent. The WHO uses a 6 point
scale to assess the pandemic threat level.
Updated Antiviral Treatment and Prophylaxis Guidance
• The Food and Drug Administration (FDA) has issued an
emergency use authorization for oseltamivir and zanamivir,
authorizing the use of oseltamivir for treatment and
prophylaxis of patients less than one year of age. Dosage
recommendations for children less than 1 year of age are
available at http://www.cdc.gov/swineflu/childrentreatment.htm
FDA has also authorized the use of both oseltamivir and
zanamivir f or use at later time points (i.e., for patients
with severe disease who have been symptomatic for more than 2
• Treatment and prophylaxis: Oseltamivir stocks in some
pharmacies are reportedly low, although the manufacturer
reports adequate supplies, and local stocks are expected to
increase. Clinicians are asked to exercise prudent judgment in
prescribing oseltamivir for patients with mild ILI who do not
have underlying medical conditions. Prescribing oseltamivir for
purposes of personal stockpiles is strongly discouraged.
Home Management of Persons with Suspected, Probable or
• Persons with suspected, probable or confirmed S-OIV continue
to be advised to stay home for 7 days after symptom onset or
24-48 hours after symptom resolution, whichever is longer.
Patients should cover their mouths and noses with a tissue or
handkerchief when coughing or sneezing, and should wash their
hands with soap and water frequently.
• We recommend that home care for persons with mild ILI be
given by one primary caregiver if possible, and that the
patient should be separated to the extent possible from other
members of the household, preferably in a separate bedroom. The
caregiver should wear a mask, either surgical or N95, when
close contact with the ill person is unavoidable. The ill
person should also wear a surgical mask when close contact with
other individuals in the home is unavoidable.
Surveillance and Reporting
• We continue to ask NYC providers to report hospitalized
patients with severe, unexplained febrile, respiratory illness
to the Provider Access Line at 1-866-NYC-DOH1 (1-866-692-3641).
Providers should continue to test only patients with severe
febrile respiratory illness for influenza A, using a
commercially available rapid test, PCR or immunofluorescence
test (e.g., DFA or IFA).
• In order to ensure that sufficient laboratory reso urces are
available, testing at the Public Health Laboratory will only be
approved for severe cases that are first reported to DOHMH via
the Provider Access Line. DOHMH staff will evaluate the case
and advise whether testing for S-OIV at the Public Health
Laboratory is indicated. DOHMH will facilitate specimen
transport and testing for cases when testing is indicated.
• The New York City case definitions for suspected, probable or
confirmed cases are unchanged.
Guidelines for management of patients with mild influenza-like
illness in New York City and infection control are unchanged.
Please see the Health Department’s website at www.nyc.gov/health for
more information on its Swine Flu page, including educational
materials for patients on respiratory and hand hygiene and STOP
triage posters for waiting areas in clinics and emergency
The CDC is updating guidance on its website daily. Please see
for updated national rec ommendations.
To contact the Health Department, including to report suspected
cases of swine influenza in hospitalized patients and arrange
for specimen testing, please call the Provider Access Line at
866-NYC-DOH1. This number is also available for questions or
consultations by providers.
As always, we appreciate the cooperation of the medical
community in New York City and will update you with further
information when it becomes available.
The Swine Influenza Investigation Team
New York City Department of Health and Mental