Influenza Season Update #2: Alert for New Hampshire Clinicians

February 05, 2015

The Centers for Disease Control and Prevention (CDC) is investigating numerous cases of influenza-associated parotitis. The clinical significance of these findings is not clear, and the CDC is continuing to investigate the clinical syndrome in order to inform prevention and control measures.

Key Points and Recommendations:

  1. The CDC nationally is investigating cases of influenza-associated parotitis.

  2. Cases of parotitis have been identified in persons with laboratory-confirmed influenza, with or without symptoms of influenza-like illness (ILI).

  3. Healthcare providers should consider testing patients for influenza who present with unilateral or bilateral parotitis without an obvious etiology.

  4. Any patient with suspected or confirmed influenza who is hospitalized, severely ill, or at high risk for influenza complications should be treated with influenza antiviral medications as soon as possible after development of ILI.

  5. Cases of laboratory-confirmed influenza with associated parotitis should be reported to the New Hampshire Division of Public Health Services (NH DPHS) at 1-603-271-4496 (after hours, 1-800-852-3345 ext.5300).

Background

While parotitis is a classic finding in mumps, there are multiple other infectious and noninfectious etiologies for parotitis. The NH DPHS has received numerous requests for mumps testing this season, but all have been so far negative.

Other common viruses that can causes parotitis include parainfluenza 3 virus, influenza A, and coxsackieviruses. Bacteria can also cause a supportive (purulent) parotitis, mostly commonly Staphylococcus aureus. Certain chronic medical conditions and noninfectious etiologies (i.e. sialadenitis) can also cause parotitis. NH DPHS recommends that providers consider testing patients presenting with parotitis, with or without ILI symptoms, for influenza. Any cases of laboratory-confirmed influenza with associated parotitis should be reported to NH DPHS at 1-603-271-4496 (after hours, 1-800-852-3345, ext. 5300).

CDC and NH DPHS continue to recommend influenza vaccination to provide protection this season against influenza, and to possibly reduce influenza-related complications. Antiviral treatment is recommended in patients suspected or confirmed to have influenza, even before confirmatory influenza testing is available, in patients who are at high risk for influenza complications, are hospitalized, or are severely ill.

Consideration should also be given for using antivirals for the prevention of influenza in high-risk individuals and during institutional outbreaks (such as in long-term care settings). NH has received several reports of ILI outbreaks this season, many occurring in long-term care settings. National antiviral supply is sufficient to meet the increased demand this season, but there may be some spot shortages. Further details on use of antiviral medications can be found in the previous HAN notice sent out by CDC and NH DPHS and a Provider Letter below for your information.

For any questions regarding the contents of this message, please contact NH DHHS, DPHS, Bureau of Infectious Disease Control at 1-603-271-4496 (after hours, 1-800-852-3345, ext.5300).

Provider Letter

January 29, 2015

Dear Colleague:

We are asking for your help in protecting young children and people 65 and older against influenza this season by implementing prompt antiviral treatment when flu is suspected. We are urging you to "think flu." Currently, influenza activity in the U.S. is high overall and is likely to continue for weeks. H3N2 viruses have been most common so far. There are typically more hospitalizations and deaths in children younger than 2 years and people 65 years and older during seasons when H3N2 viruses predominate.

It is important that we do everything we can to protect people in these two age groups from flu. The first and most important step for flu prevention is getting a flu vaccine; however, preliminary vaccine effectiveness results of about 23% indicate that the vaccine is working less well this season, likely because of substantial antigenic and genetic drift among circulating H3N2 viruses, which are dominating so far this season. So, we are urging you to also "think flu treatment." In the context of widespread circulation of H3N2 and reduced vaccine effectiveness, prompt antiviral treatment of severely ill and high risk patients becomes even more important as a second line of defense in reducing flu complications and death.

Your recommendations make a difference to your patients. Here are some key points to consider about the importance of flu vaccination and prompt treatment for flu, particularly in high risk patients:

  • Children younger than 2 years, and people 65 and older are at high risk for complications from the flu. These two age groups have the highest flu hospitalization rates.

  • Antiviral drugs are an important second line of defense to treat flu illness. (They are not a substitute for vaccination.)

  • Data indicate that flu antiviral drugs can reduce symptoms and prevent serious flu complications.

  • For high risk patients, antiviral drugs can mean the difference between a milder illness and a hospital stay.

  • Antiviral drugs are under-utilized. A recent study showed that only 19% of high risk outpatients who had the flu were treated with flu antiviral drugs.

  • CDC recommends that all severely ill people and people who are at high risk of serious flu complications with suspected flu be treated with flu antiviral drugs as soon as possible (without confirmatory testing).

  • Studies show that flu antiviral drugs work best for treatment when they are started within 2 days of getting sick. However, starting them later may still be helpful.

  • There are three FDA-approved influenza antiviral drugs recommended by CDC this season. The brand names for these are Tamiflu® (generic name oseltamivir), Relenza® (generic name zanamivir), and Rapivab® (generic name peramivir). Peramivir was approved in December 2014. It is given by IV.

  • Even though vaccine effectiveness for H3N2 is reduced this season, CDC continues to recommend vaccination because it may still provide some protection, including reducing more severe flu outcomes like hospitalization and death. Also, flu vaccines protect against three or four different viruses and it's possible that other viruses will circulate later in the season.

Your role in ensuring your patients are protected against influenza is crucial. We hope this information will be beneficial to you to as you treat your patients this flu season. More information can be found at: http://www.cdc.gov/flu/antivirals/index.htm.

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