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When Should I Suspect Avian H5N1 Influenza and How Do I Report It?
Providers should take a travel history on all patients presenting with a febrile respiratory syndrome and should report immediately any suspect cases of avian H5N1 influenza meeting the following clinical AND epidemiologic criteria. Reports should be made to the New York City Health Department at the contact numbers listed below so that testing for avian H5N1 influenza can be arranged:
- Testing for the following patients is recommended:
A patient who has an illness that requires hospitalization or is fatal; and has a documented temperature of ≥38°C (≥100.4° F); and has radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established; and has at least one of the following potential exposures within 10 days of symptom onset:
- History of travel to a country with influenza H5N1 documented in poultry, wild birds, AND/or humans†, and had at least one of the following potential exposures during travel:
- direct contact with (e.g., touching) sick or dead domestic poultry;
- direct contact with surfaces contaminated with poultry feces;
- consumption of raw or incompletely cooked poultry or poultry products;
- direct contact with sick or dead wild birds suspected or confirmed to have influenza H5N1;
- close contact (approach within 1 meter [approx. 3 feet]) of a person who was hospitalized or died due to a severe unexplained respiratory illness;
- Close contact (approach within 1 meter [approx. 3 feet]) of an ill patient who was confirmed or suspected to have H5N1;
- Worked with live influenza H5N1 virus in a laboratory.
- Testing for the following patients will be considered on a case-by-cases basis in consultation with the New York City Health Department:
- A patient with mild or atypical disease‡ (hospitalized or ambulatory) who has one of the exposures listed above (criteria A, B, or C); OR
- A patient with severe or fatal respiratory disease whose epidemiological information is uncertain, unavailable, or otherwise suspicious but does not meet the criteria above (examples include: a returned traveler from an influenza H5N1-affected country whose exposures are unclear or suspicious, a person who had contact with well-appearing poultry, etc.)
Report Immediately Any Suspected Cases of Avian H5N1 Influenza:
To report patients meeting the above criteria:
During business hours, please contact the DOHMH Bureau of Communicable Disease at 212-788-9830 and ask to speak to the Doctor of the Week.
During non-business hours, please call the New York City Poison Control Center at 1-800-222-1222 or 212-764-7667 and ask to speak to the On Call Physician.
The New York City Health Department physician will review the case with you to determine if H5N1 testing is indicated based on risk exposure history.
† For a listing of influenza H5N1-affected countries, visit the CDC website; the OIE website; and the WHO website.
‡ For example, a patient with respiratory illness and fever who does not require hospitalization, or a patient with significant neurologic or gastrointestinal symptoms in the absence of respiratory disease.
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Clinical Guidelines: Caring for Patients with Suspected or Confirmed Avian H5N1 Influenza
All patients who meet clinical and epidemiologic criteria for avian H5N1 influenza should be reported immediately to DOHMH (See Part 1: When Should I Suspect Avian H5N1 Influenza and How Do I Report It?). The following clinical guidance should be followed:
Admitting Suspect Avian H5N1 Influenza Patients
- Providers are encouraged to admit patients with suspected avian H5N1 influenza to ensure that infection control precautions are enforced and to enhance the ability to monitor the patient's condition. Especially in those cases where avian H5N1 influenza is strongly suspected (e.g., known exposure to confirmed human case or infected poultry overseas), the patient should be admitted to the hospital until laboratory test results are available to confirm or rule out H5N1 infection. For highly suspect cases who refuse hospital admission, the New York City Department of Health and Mental Hygiene (DOHMH) has the authority to detain patients in the hospital suspected of having a communicable disease that may pose an imminent and significant threat to the public health for evaluation, if indicated, while awaiting laboratory test results (Section 11.55 in the NYC Health Code).
- The decision to hospitalize a suspected avian H5N1 influenza case will be based on the physician's clinical evaluation and assessment of epidemiologic risk factors, on whether adequate precautions can be taken at home to prevent the potential spread of infection, and on whether the patient will be readily available for follow up. (NOTE: Suspect cases occurring among tourists staying at a hotel or in persons living in congregate settings may need to be hospitalized while awaiting laboratory test results.)
- Despite the current low risk of person-to-person transmission, suspect case-patients who are being cared for at home should be separated from other household members as much as possible. All household members should carefully follow recommendations for hand hygiene, and tissues used by the ill patient should be placed in a plastic bag and disposed with other household waste. Although no studies have assessed the use of masks at home to decrease the spread of infection, use of surgical or procedure masks by the patient and/or caregiver during interactions may be of benefit. Separation of eating and drinking utensils for use by a patient with influenza is not necessary, as long as they are washed with warm water and soap. (See Part 5: Management of Avian H5N1 Influenza at Home)
Infection Control Measures
- Obtain clinical specimens for avian H5N1 influenza diagnostic testing. (See Part 4: What Specimens Should Be Collected for Avian H5N1 Influenza Testing?). Complete the specimen submission form (Virus Detection Laboratory Submission Form) and INCLUDE the form with the specimens. A DOHMH courier will pick up the specimens and transport them to appropriate public health reference laboratories for testing. Do not send specimens for viral culture to a hospital or commercial laboratory; for safety reasons, avian H5N1 influenza may only be cultured in Basic Safety Level 3+ laboratory facilities. DOHMH personnel will maintain contact with the patient's providers to ensure timely relaying of testing results.
- Evaluate alternative diagnoses. An alternative diagnosis should be based on laboratory tests with high positive-predictive value (e.g., blood culture, PCR, Legionella urinary antigen, pleural fluid culture, transthoracic aspirate culture, etc.). If an alternate etiology is identified, the possibility of co-infection with an avian H5N1 influenza virus may still need to be considered if there is a strong epidemiologic link with possible exposure to an infected human or birds overseas.
- Initiate antiviral treatment with oseltamivir (Tamiflu) or zanamivir (Relenza) – the neuraminidase inhibitors - as soon as possible, even if laboratory results are not yet available (see Table below for dosing regimens.) Oseltamivir is available both in pill and suspension form, and zanamivir is available as an inhaled powder. The neuraminidase inhibitors are preferred because the majority of avian H5N1 influenza A viruses currently affecting humans are resistant to amantadine and rimantadine, and resistance to adamantanes typically develops rapidly when they are used for treatment of influenza. Viral isolates from any case of avian H5N1 influenza will be tested by CDC for resistance to the currently licensed antiviral medications.
- Clinical trials have shown that neuraminidase inhibitors can decrease the illness duration due to seasonal influenza by one to two days when they are initiated within 48 hours of illness onset. The clinical effectiveness of antiviral drugs for treatment of avian H5N1 influenza is unknown, but it is likely that the earlier treatment is initiated, the greater the likelihood of benefit.
- Oseltamivir is available as an oral suspension for use in children. However, none of the available influenza antivirals is currently FDA-approved for use among children aged <1 year. In particular, the safety and efficacy of oseltamivir have not been studied in children aged <1 year for either treatment or prophylaxis of influenza. The decision by an individual physician to treat children aged <1 year in an emergency setting with an antiviral medication on an off-label basis must be made on a case-by-case basis, with full consideration of the potential risks and benefits.
- Though human-to-human transmission of avian H5N1 influenza has occurred only very rarely, DOHMH personnel will assist providers in identifying and monitoring close contacts of suspected or confirmed avian H5N1 influenza patients. Such contacts might include household and social contacts, family members, workplace or school contacts, and/or healthcare providers who had unprotected close contact (i.e., did not use droplet or standard precautions) starting 24 hours prior to the patient's symptom onset.
- Asymptomatic contacts should be asked to take their temperature at least twice daily. In conjunction with DOHMH, asymptomatic contacts should be monitored by telephone or home visit daily for 10 days after their last contact with the suspected case-patient to assess for development of symptoms consistent with avian H5N1 influenza. Asymptomatic contacts should not be given antiviral chemoprophylaxis unless they develop symptoms or signs consistent with influenza infection. Quarantine of asymptomatic contacts at home or in another facility is not considered necessary at the present time based on the epidemiologic characteristics of the current avian H5N1 influenza outbreak in Asia and Europe.
- Symptomatic contacts of suspected avian H5N1 influenza patients should seek medical attention immediately when symptoms develop and should notify their healthcare provider of recent contact with a suspected avian H5N1 influenza case (See Part 3: Avian H5N1 Influenza Infection Control Precautions and Guidance for Contacts). The DOHMH should be immediately notified of any contact who develops fever and respiratory symptoms suggestive of avian H5N1 influenza infection; recommendations on whether empiric antiviral treatment is indicated for symptomatic contacts will be made on a case-by-case basis.
Patients Testing Positive for Avian H5N1 Influenza:
- Patients with laboratory-confirmed avian H5N1 influenza should be isolated and treated with a neuraminidase inhibitor.
- Healthcare personnel should use standard and droplet infection control precautions; airborne precautions should be used during procedures that may generate aerosols (e.g., bronchoscopy or intubation).
- Avian H5N1 influenza patients should be isolated from patients with seasonal influenza, since such measures may decrease the risk of co-infection and viral genetic reassortment.
- For patients suspected to have secondary bacterial infections (e.g., pneumonia due to pneumococci or staphylococci, including methicillin-resistant strains), appropriate antibacterial therapy should be employed. Supportive measures such as intravenous fluids, parenteral feeding, and intubation with mechanical ventilation should be employed as medically indicated.
- There are currently no data to suggest that corticosteroids or other disease modifying agents (e.g., anti-tumor necrosis factor agents) are effective in the treatment of avian H5N1 influenza.
Table. Recommended Daily Dosage of Antivirals for Treatment and Prophylaxis
(Adapted from Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices [ACIP], July 2005)
| ||Age Groups (years)|
|Treatment, influenza A (duration 5 days)||5mg/kg body weightper day up to 150 mg in two divided dosesb||5mg/kg body weight per day up to 150 mg in two divided dosesb||100 mg twice dailyc||100 mg twice dailyc||<100 mg per day|
|Prophylaxis, influenza A||5mg/kg body weight per day up to 150 mg in two divided dosesb||5mg/kg body weight per day up to 150 mg in two divided dosesb||100 mg twice dailyc||100 mg twice dailyc||<100 mg per day|
|Treatment,e influenza A (duration 5 days)||NAf||NA||NA||100 mg twice dailyc,g||100 mg per day|
|Prophylaxis, influenza A||5m/kg body weight per day up to 150 mg in two divided dosesb||5mg/kg body weight per day up to 150 mg in two divided dosesb||100 mg twice dailyc||100 mg twice dailyc||100 mg per dayh|
|Treatment, influenza A and B (duration 5 days)||NA||10 mg twice daily||10 mg twice daily||10 mg twice daily||10 mg twice daily|
|Treatment,k influenza A and B (duration 5 days)||dose varies by child's weightl||dose varies by child's weightl||dose varies by child's weightl||75 mg twice daily||75 mg twice daily|
|Prophylaxis, influenza A and B||NA||NA||NA||75 mg per day||75 mg per day|
NOTE: Amantadine manufacturers include Endo Pharmaceuticals (Symmetrel (R)–tablet and syrup) and Geneva Pharms Tech (Amantadine HCL–capsule); USL Pharma (Amantadine HCL–capsule and tablet); and Alpharma, Carolina Medical, Copley Pharmaceutical, HiTech Pharma, Mikart, Morton Grove, and Pharmaceutical Associates (Amantadine HCL–syrup), and Sandoz. Rimantadine is manufactured by Forest Laboratories (Flumadine (R)–tablet and syrup); Corepharma , Impax Labs (Rimantadine HCL–tablet), and Amide Pharmaceuticals (Rimantadine HCL–tablet). Zanamivir is manufactured by GlaxoSmithKline (Relenza (R)–inhaled powder). Oseltamivir is manufactured by Roche Pharmaceuticals (Tamiflu (R)–tablet). Information based on data published by the U.S. Food and Drug Administration at www.fda.gov, accessed 3/30/2005.
- The drug package insert should be consulted for dosage recommendations for administering amantadine to persons with creatinine clearance <50 ml/min/1.73m2.
- 5 mg/kg body weight of amantadine or rimantadine syrup = 1 tsp/2.2 lbs.
- Children aged >10 years who weigh <40 kg should be administered amantadine or rimantadine at a dosage of 5 mg/kg body weight per day.
- A reduction in dosage to 100 mg per day of rimantadine is recommended for persons who have severe hepatic dysfunction or those with creatinine clearance <10 ml/min. Other persons with less severe hepatic or renal dysfunction taking 100 mg per day of rimantadine should be observed closely, and the dosage should be reduced or the drug discontinued, if necessary.
- Approved by FDA only for treatment among adults.
- Not applicable.
- Rimantadine is approved by FDA for treatment among adults. However, certain experts in the management of influenza consider it appropriate for treatment among children. (See American Academy of Pediatrics, 2003 Red Book.)
- Older nursing home residents should be administered only 100 mg per day of rimantadine. A reduction in dosage to 100 mg per day should be considered for all persons aged >65 years if they experience possible side effects when taking 200 mg per day.
- Zanamivir administered via inhalation using a plastic device included in the medication package. Patients will benefit from instruction and demonstration of the correct use of the device.
- Zanamivir is not approved for prophylaxis.
- A reduction in the dose of oseltamivir is recommended for persons with creatinine clearance <30 ml/min.
- The dose recommendation for children who weigh <15 kg is 30 mg twice a day. For children who weigh >15 to 23 kg, the dose is 45 mg twice a day. For children who weigh >23 to 40 kg, the dose is 60 mg twice a day. And for children who weigh >40 kg, the dose is 75 mg twice a day.
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Infection Control Precautions and Guidance for Contacts
Avian H5N1 Influenza Transmission
Most information on the modes of influenza transmission from person to person is indirect and largely obtained through observations during outbreaks in healthcare facilities and other settings (e.g., cruise ships, airplanes, schools, and colleges); the amount of direct scientific information is very limited. However, the epidemiologic pattern observed is generally consistent with spread through close contact (i.e., exposure to large respiratory droplets, direct contact, or near-range exposure to aerosols). While some observational and animal studies support airborne transmission through small particle aerosols, there is little evidence of airborne transmission over long distances or prolonged periods of time (as is seen with tuberculosis). The relative contributions and clinical importance of the different modes of influenza transmission are currently unknown.
For patients meeting clinical and epidemiologic criteria for suspected avian H5N1 influenza infection (See Part 1: When Should I Suspect Avian H5N1 Influenza and How Do I Report It?), the following infection control procedures should be followed pending laboratory test results:
- Patients should be admitted to a single-patient room, and patient movement and transport within the hospital should be limited to medically necessary purposes.
- Do not send specimens for viral culture to a hospital or commercial laboratory; for safety reasons, avian H5N1 influenza may only be cultured in Basic Safety Level 3+ laboratory facilities. DOHMH personnel will assist in arranging laboratory testing at appropriate public health reference laboratories (See Part 4: What Specimens Should Be Collected for Avian H5N1 Influenza Testing?) and will maintain contact with the patient's providers to ensure timely relaying of testing results.
- While awaiting avian H5N1 influenza test results, patients should be placed on Droplet Precautions*? Healthcare personnel should wear surgical or procedure masks on entering a patient's room, as per Droplet Precaution recommendations, as well as gloves and gowns when indicated for Standard Precautions (i.e., wear gloves when patient contact is suspected, and wear gown when soiling of providers clothes with patient's body fluids is possible).
- Airborne isolation procedures, including moving patient to an airborne infection isolation room (AIIR) and using N95 respirators, should be used during procedures with the potential to generate aerosols (e.g., collection of respiratory specimens, intubation, bronchoscopy, and nebulizer treatments). Wearing goggles or face shield for routine contact with suspect avian H5N1 influenza patients is not necessary unless sprays or splatter of infectious material is likely.
Patients Testing Positive For Avian H5N1 Influenza
- Infection control precautions for confirmed avian H5N1 influenza patients are the same as for those with suspect disease. Droplet Precautions should remain in place until there is full resolution of illness. Healthcare personnel should continue to wear surgical or procedure masks on entering a patient's room, as per Droplet Precautions, as well as gloves and gowns when indicated for Standard Precautions. As with suspect disease, airborne isolation procedures should be used during procedures with the potential to generate aerosols.
Management of Contacts of Suspect Cases
- Determine whether any close contacts (e.g., household, sexual, etc.) of the suspected case currently have fever and respiratory symptoms. If symptomatic contacts report avian H5N1 influenza risk exposures, they should be treated as a suspect case. If the symptomatic contact reports no risk exposures except contact with the suspected avian H5N1 patient, and after a medical evaluation they are they are not deemed ill enough to require hospitalization based on clinical criteria, advise them to stay home and follow what the Centers for Disease Control and Prevention (CDC) has called "cough etiquette":
The DOHMH will provide consultation on whether empiric antiviral treatment should be started for symptomatic contacts on a case-by-case basis.
- Cover nose and mouth when coughing or sneezing;
- Use tissues to contain respiratory secretions and, after use, dispose in the nearest waste receptacle; and
- Wash hands with non-antimicrobial soap and water, alcohol-based hand rub or antiseptic handwash after having contact with contaminated respiratory secretions or objects/materials that may be contaminated.
- Asymptomatic contacts, including hospital contacts, should be asked to take their temperature at least twice daily. In conjunction with DOHMH, asymptomatic contacts should be monitored by telephone or home visit daily for 10 days after their last contact with the suspected case-patient to assess for development of symptoms consistent with avian H5N1 influenza. Asymptomatic contacts should not be given antiviral chemoprophylaxis. Quarantine of asymptomatic contacts at home or in another facility is not considered necessary at the present time based on the epidemiologic characteristics of the current avian H5N1 influenza outbreak in Asia and Europe.
- If an asymptomatic contact subsequently develops fever or respiratory symptoms, they should contact their healthcare provider and inform them of their exposure to a suspected avian H5N1 influenza case before proceeding to the provider's office or clinic so that proper infection control measure may be implemented when they arrive. The DOHMH should also be notified immediately.
- For symptomatic contacts, DOHMH will facilitate diagnostic testing, including guidance for specimen collection, transport of specimens, and relaying of testing results back to providers. In addition, DOHMH will ensure that contacts of the symptomatic contact know of their possible exposure, and that they self-monitor for fever daily.
*NOTE: Current interim guidance from the Centers for Disease Control and Prevention recommends the use of standard and droplet precautions when caring for patients with suspected or confirmed avian H5N1 influenza based on the current epidemiology of the outbreak in Asia, Europe and Africa. If the epidemiologic and clinical characteristics of the virus change in the future, this recommendation may need to be modified accordingly.
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What Specimens Should Be Collected for Testing?
Testing for Avian H5N1 Influenza
Testing for avian H5N1 influenza may only be carried out in a reference laboratory (e.g., authorized state or local public health laboratory or CDC). Testing may be done on respiratory samples by reverse transcriptase polymerase chain reaction (RT-PCR) testing (see below), and serological confirmation may also be carried out. In addition, post-mortem testing on various tissues is also available. Viral culture is not recommended on specimens of any kind from patients with suspected avian H5N1 influenza due to biosafety concerns. Culturing avian H5N1 influenza viruses may only occur in a Biosafety Level 3+ laboratory, which currently excludes all New York City (NYC) hospital and commercial laboratories. Viral culture for avian H5N1 influenza is currently available at the New York State Department of Health and the Centers for Disease Control and Prevention.
The following respiratory specimens should be collected and stored at 4oC for both RT-PCR and viral culture testing. All suspected cases should be reported immediately to the NYC Department of Health and Mental Hygiene (DOHMH). After arrangements have been made with DOHMH (See Part 4: When Should I Suspect Avian H5N1 Influenza and How Do I Report It?), a DOHMH courier will transport specimens to the Public Health Laboratory.
At least one nasopharyngeal (NP) AND one oropharyngeal (OP) swab should be collected as follows:
- Collect specimen with a sterile Dacron/nylon swab with a non-wooden shaft (Do NOT use calcium alginate swabs or swabs with wooden sticks).
- For NP swab, insert swab into nostril parallel to the palate until the tip reaches the nasopharynx, and leave in place for a few seconds to absorb secretions. For OP swab, swab the posterior pharynx and tonsillar areas, avoiding the tongue.
- Place swab immediately into sterile vials containing 2 ml of viral transport media. Label each specimen container with patient's FIRST AND LAST NAME, date of birth, medical record number, date of collection, and specimen type.
- Place specimen vial onto ice or in refrigerator prior to and during transport to laboratory. Do not freeze.
- Avoid delay in transport and testing.
- An OP swab may be more likely than an NP swab to yield a positive result. While both types of specimens should be collected, an OP swab should be performed preferentially if only one sample can be taken.
Nasopharyngeal wash/aspirates may also be used for diagnosis of avian H5N1 influenza. It is recommended that nasal wash/aspirate be collected as follows:
- Have the patient sit with head tilted slightly backward. Instill 1ml.-1.5ml. of bacteriostatic saline (pH 7.0) into one nostril.
- Insert the tubing into the nostril parallel to the palate.
- Aspirate nasopharyngeal secretions. Repeat this procedure for the other nostril.
- Rinse catheter into viral transport medium (syringe or bulb) or aspirate viral transport medium through catheter into collection trap.
- Place specimen onto ice or in refrigerator prior to and during transport to laboratory. Do not freeze.
- Avoid delay in transport and testing.
An acute serum sample should also be obtained from all suspect cases as follows:
- 5-10 ml whole blood in a serum separator or red top tube.
- Spin down and refrigerate at 4oC.
- Label each specimen container with patient's FIRST AND LAST NAME, medical record number, date of birth, specimen type, and collection date.
All information requested on the "Virus Detection Laboratory Submission Form" should be completely filled out and the form should be included with the specimen shipment.
In fatal cases associated with suspected avian H5N1 influenza infection, DOHMH personnel will help make arrangements for autopsy and coordinate specimen shipping and testing with the NYC Office of the Chief Medical Examiner and CDC.
Rapid Testing for Avian H5N1 Influenza
Rapid influenza diagnostic tests and immunofluorescence (indirect fluorescent antibody staining [IFA] or direct fluorescent antibody staining [DFA]) may be used to detect seasonal human strains of influenza, but should not be used to confirm or exclude avian H5N1 influenza. Rapid influenza tests have relatively low sensitivity for detecting seasonal influenza, and their ability to detect avian H5N1 influenza is unknown. The sensitivity of rapid diagnostic tests will likely be higher in specimens collected within two days of illness onset, in children, and when tested in clinical laboratories that perform a high volume of testing. Such tests can identify influenza A viruses but cannot distinguish between human infection with seasonal and avian H5N1 influenza viruses. A negative rapid influenza test result does not exclude human infection with either seasonal or avian H5N1 influenza viruses. A positive rapid influenza test result could be a false positive or represent infection with either seasonal or avian H5N1 influenza viruses. Therefore, both negative and positive rapid influenza test results and immunofluoresence results should be interpreted with caution, and RT-PCR testing for suspected avian H5N1 influenza virus should be performed in a reference laboratory, as outlined above.
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Management of Avian H5N1 Influenza at Home
The current strain of avian influenza H5N1 circulating in Asia, Europe and Africa has not demonstrated the ability to spread easily from human to human. Although the risk of transmission of influenza virus to household members and care givers, is thought to be extremely low, the following guidelines should be adhered to for 7 days after the patient's onset of fever1:
- If available, the patient should wear a surgical mask home from the clinic or hospital. The mask should be worn around other people for 7 days after the first day of fever, even while at home. The mask should be changed daily, or sooner if it gets wet or soiled.
- Designate one person as the primary care provider. Other persons living in the home should limit contact with the patient to the extent possible. They should sleep in a separate room; avoid close contact such as kissing; and should not share toothbrushes, cigarettes or drinks with non-infected persons.
- Other visitors who are not essential for patient care should not enter the home while the patient is ill with influenza. If unexposed persons must enter the home, they should avoid close contact with the patient.
- The patient should be reminded to cover their mouth and nose with a tissue when sneezing, coughing or blowing the nose – and to wash their hands after throwing the used tissue in the garbage. Used tissues and face masks can be discarded with the regular garbage. Hands should be washed with soap and water or with an alcohol-based hand rub.
- If any body fluids (such as secretions from the nose or mouth, urine, vomit or stool) gets on surfaces in the home (such as door knobs or any other object that you sneeze or cough on), the surface should be washed with any standard household cleaner or disinfectant. Rinse the surface with tap water afterwards. If someone else does the cleaning, he/she should wear rubber gloves.
- Soiled dishes and eating utensils should be washed either in a dishwasher or by hand with warm water and soap. Separation of eating utensils for use by a patient with influenza is not necessary. Laundry can be washed in a standard washing machine with warm or cold water and detergent. It is not necessary to separate soiled linen and laundry used by a patient with influenza from other household laundry. Care should be used when handling soiled laundry (i.e., avoid "hugging" the laundry) to avoid contamination. Hands should be washed after handling soiled laundry.
- If the patient needs to go to the doctor's office, a family member or friend should drive them in a private car and they should not take public transportation (subway or bus). The doctor's office or clinic should be called to let them know that the patient is a suspected or confirmed case of avian influenza. If possible, the patient should wear a surgical mask, and should go straight to the receptionist on arrival so that he/she can be put in a private room while waiting to see the doctor.
1NOTE: The potential period of contagiousness for the current strain of avian H5N1 influenza if it develops the ability to be transmissible from humans to humans is not known at this time. If new information becomes available based on epidemiologic studies, the recommended timeframe of 7 days may need to be changed.
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