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This is an official
CDC HEALTH ADVISORY

Distributed via Health Alert Network
 17:45  EST (5:45  PM EST)
CDCHAN-00115-03-02-26-ADV-N

Recommendations to Enhance US Surveillance for Influenza A(H5N1)

As you are aware, two human cases of influenza A (H5N1) have been confirmed in a single family of Hong Kong residents who recently traveled to Fujian Province on mainland China. The first patient, a 9-year-old boy, was hospitalized in Hong Kong but is recovering. The second patient, the father of the 9-year-old boy, died in a Hong Kong hospital on February 17, 2003. Additional family members had respiratory symptoms, and the boy's 8-year-old sister died while the family was in China. The cause of her death and the other respiratory illnesses in her family is not known. There is currently insufficient information to determine whether this family was infected from a common source or whether illness spread within the family from person to person.

In response to the reports of these 2 cases, CDC is issuing recommendations for enhanced influenza surveillance for state health departments. The purpose of these recommendations is to enhance the capacity to rapidly identify an importation of influenza A (H5N1) into the United States from Asia while maintaining effective public health response capacity. The enhancements will occur in a stepwise fashion based on the evolution of influenza A (H5N1) activity.

Enclosed are recommendations for enhanced influenza surveillance activities that should be implemented immediately as well as activities that should be implemented if influenza A (H5N1) cases are identified outside Hong Kong or the Chinese mainland or evidence of efficient, sustained, person-to-person transmission is established. We will continue to provide you with updates on influenza A (H5N1) activity and will distribute recommendations on any additional surveillance activities that may become necessary.

Thank you for your time and help with these efforts. If you have any questions, please contact Lynnette Brammer (lbrammer@cdc.gov) or Alicia Postema (apostema@cdc.gov) at 404-639-3747.

Sincerely,

Lynnette Brammer, MPH

Influenza Branch

Centers for Disease Control and Prevention

1600 Clifton Rd., MS A-32

Atlanta, GA 30333

Phone: 404-639-3747

Fax: 404-639-3866

RECOMMENDATIONS TO ENHANCE SURVEILLANCE FOR INFLUENZA A(H5N1)

February 26, 2003

Objective

To enhance the capacity to rapidly identify an importation of influenza A(H5N1) into the United States from Asia while maintaining effective public health response capacity.

Recommendations

Surveillance enhancements will occur in a stepwise fashion based on the evolution of influenza A(H5N1) activity.

Step 1. Activities for immediate implementation

Laboratory surveillance

All US World Health Organization/National Respiratory and Enteric Virus Surveillance System collaborating laboratories should subtype all influenza A viruses identified in clinical specimens, if possible. As always, any unsubtypable influenza A virus should be reported to the CDC Influenza Branch immediately (Dr. Alexander Klimov, 404-639-3591).

Sentinel provider surveillance:

States at less than 75% of their sentinel provider goal of 1 regularly reporting site per 250,000 population (or a minimum of 10 sites in smaller, less populous states) should consider recruiting and enrolling additional providers to allow for tracking the impact and intensity of activity of any potential pandemic influenza in their state. To enroll additional providers, contact Alicia Postema at 404-639-3747 or by email at apostema@cdc.gov.

During the past several years, many states have conducted influenza surveillance year round, including the summer months. To enhance surveillance nationwide, we strongly encourage all states to adopt this practice and continue both laboratory and sentinel provider surveillance activities year round, uninterrupted.

Hospital-based specimen collection

States should ask hospitals to perform viral culture on all patients meeting both of the following criteria:

1. Patient hospitalized with unexplained pneumonia, acute respiratory distress syndrome (ARDS), or severe respiratory illness

2. Travel to Asia within 10 days from onset of symptoms

All such patients should be tested for influenza virus infection by viral culture of nasopharyngeal and throat swabs. All influenza viruses detected should be typed and subtyped, and those not identified as H3, H1, or B should be referred immediately to CDC for testing for influenza A(H5N1). Laboratory recommendations for handling potential H5N1 samples will follow in the near future.

Mortality surveillance

CDC will continue to track mortality through the 122 Cities Mortality Reporting System. We will be able to analyze these data on a national and potentially regional basis only. This system is based on only a sample of deaths and cannot provide state-based estimates of mortality. States anticipating the need to report deaths on a state level in the event of a pandemic should begin to explore other options for data collection.

Step 2. Activities to be implemented if cases of influenza A(H5N1)illness are identified outside Hong Kong or the Chinese mainland OR evidence of efficient, sustained, person-to-person transmission is established

Laboratory surveillance

US WHO collaborating laboratories will be requested to report more frequently and should anticipate the possible need for daily reporting. Any state laboratories wishing to institute electronic reporting through the Public Health Laboratory Information System (PHLIS) should contact Lynnette Brammer at 404-639-3747 or by email at lbrammer@cdc.gov. Instructions for frequent reporting by other methods will follow.

Hospital-based surveillance

CDC is exploring options for hospital-based surveillance for influenza-related hospital admissions. More information will follow in the near future.

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national and international organizations.

DEPARTMENT OF HEALTH AND HUMAN SERVICES


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