May 1, 2013 (Revised from April 12, 2013)

The U.S. Centers for Disease Control & Prevention (CDC) has updated its interim guidance: 

Antiviral Treatment: Due to the potential severity of illness associated with Avian Influenza A:H7N9 virus infection, CDC now recommends that all confirmed, probable, and suspect cases of Avian Influenza A:H7N9, including outpatients with uncomplicated illness, be treated with neuraminidase inhibitors as early as possible, without waiting for laboratory confirmation of influenza before initiating treatment.

Infection Control Guidance has been updated; Droplet precautions are no longer recommended but Standard, Contact and Airborne precautions should be implemented by health care personnel; suggestions are provided for clinics unable to fully implement Airborne Precautions.

Case Definitions: A definition for Suspect cases (Cases Under investigation) has been added, defining Suspect as patients with influenza-like illness (ILI1) with:

• Recent contact (within ≤ 10 days of illness onset) with a confirmed or probable case of infection with Avian Influenza A:H7N9 virus; or
• Recent travel (within ≤ 10 days of illness onset) to a country where human cases of Avian Influenza A:H7N9 virus have been recently detected or where Avian Influenza A:H7N9 viruses are known to be circulating in animals. (As of 4/29/13, those countries are China and Taiwan).

Actions Requested of Clinicians

1. IMPLEMENT Standard, Contact and Airborne Precautions2, including eye protection and respirators, for health care personnel caring for patients meeting criteria for a Suspect case of Avian influenza A:H7N9. Place a surgical mask on the patient to reduce spread of respiratory secretions and have the patient avoid public settings (e.g., public transportation). Aerosol-generating procedures should be performed only if they are medically necessary and cannot be postponed.
2. REPORT suspected Avian influenza A:H7N9 in patients who meet the criteria described in the case definition for case under investigation (CUI). Call the SFDPH Communicable Disease Control Unit at (415) 554-2830; after hours, weekends and holidays press “1” and “1” again to page the on call physician.
3. COLLECT specimens for testing and, after obtaining approval from SFDPH Communicable Disease Control, send specimens to SFDPH Public Health Laboratory per instructions below.
4. TREAT empirically with neuraminidase influenza antiviral medications (oral oseltamivir or inhaled zanamivir) as soon as possible, without waiting for laboratory confirmation in all patients who meet the case definition for case under investigation, including outpatients with uncomplicated illness.
5. CONSULT an infectious disease specialist and/or the CDC webpage3 for updated information

Click here to view the SFDPH health advisory on Avian Influenza A: H7N9.

For more information about health alerts, advisories, and updates from the San Francisco Department of Public Health, please visit http://www.sfcdcp.org/healthalerts.html. 

The 2012 SFMS delegation to the California Medical Association’s (CMA) annual House of Delegates meeting took a wide range of proposed resolutions for consideration by the statewide gathering. Each resolution, some with modification, moved important health care issues forward in the areas of health care delivery, health care mandates, and pharmaceutical industry issues, including medication disposal and insurance coverage.

Our roster of policy proposals this year, with outcomes, included: 

Tracking Prescriptions to Curtail Medication Abuse (Rokeach, Loring, Turner): CMA supports the development of a fully functional, Web-based prescription drug monitoring program (PDMP), whether it be an improved CURES (Controlled Substances Review and Evaluation System) program or a new one that should be fully funded, including through a fee-per-prescription paid by manufacturers and suppliers of drugs monitored.

Reducing Overutilization: Physician Leadership (Denys, Fung, Eng): CMA supports physician-led, evidence-based efforts to improve appropriate use of medical services and will educate physicians, hospitals, health care leaders, and patients about the need for physician-led, evidence-based efforts to improve appropriate use of medical services. This resolution originally referred to the “Choosing Wisely” effort that will be the topic of the January/February 2013 edition of San Francisco Medicine. 

"Pay for Delay" Practices on Generic Medications (Susens): CMA will ask AMA to support federal legislation that makes tactics delaying conversion of medications to generic status, also known as “pay for delay,” illegal in the United States. As noted in a recent NEJM piece, that might already be the case!

Increasing Utilization of POLST Orders (Newman, Schickedanz, Lopato): CMA encourages physicians to become educated about all aspects of the POLST form and to integrate discussions about, and use, POLST in all appropriate instances where medical services are provided to patients at the end of life. Surprisingly to many, this was perhaps the most hotly debated resolution of the year, as our original allowed for nurse practitioners to fill out POLST forms for physician confirmation, as is done in some other states.

Medical Mandates for Insurance Coverage and Medi-Cal (Chan): CMA supports the principle that mandated coverage for private insurers should also apply to publicly financed entities, when appropriate; and will advocate that the state legislature must budget for the increased cost to Medi-Cal and enrollees of the California Health Benefit Exchange when passing mandated coverage. 

Promoting Quality and Transparency in Graduate Medical Education (Schickedanz): CMA supports efforts to urgently address the anticipated imbalance between the number of medical school graduates and available residency training positions; and greater transparency at all levels in the calculation, distribution, and tracking of graduate medical education (GME) funding; and will petition the Centers for Medicare and Medicaid Services to address perceived disparities in the distribution of GME funding.

Cell Phone Use in Cars (Udovic-Constant, Fouras): CMA will support public education efforts regarding the dangers of distracted driving, particularly activities that take drivers’ eyes off the road, and will ask the AMA to do likewise. Our original was more forceful, asking for more severe penalties and even bans.

There was much more, with something of interest to every specialty, practice setting, and personality.

Click here to view the full list of the new policies adopted at the 2012 CMA House of Delegates.

Interested in submitting a resolution or suggesting a resolution idea for 2013 HOD? Please contact SFMS at membership@sfms.org.

68% of voters said they would support a tax on sugar-sweetened beverages if the revenue boosted school nutrition and physical activity programs, according to a new Field Poll.

The poll—conducted on behalf of the California Endowment—surveyed 1,184 registered California voters by telephone in October 2012.

According to the poll, 75% of respondents said that regularly drinking sugar-sweetened sodas increases the chance of individuals becoming overweight, while 42% said the same for sugar-sweetened energy drinks, and 26% said the same for sugar-sweetened sports drinks.

The SFMS and CMA have been strong advocates on combating child obesity. CMA took a policy position in support of the ban after its House of Delegates approved the resolution submitted by SFMS members Shannon Udovic-Constant, Arti Desai, and Adam Shickedanz introduced the resolution “Marketing of Unhealthy Food and Beverages to Children” at the 2011 HOD.

Additionally, CMA sponsored AB 1746, which would ban the sale of sugary sports drinks on middle and high school campuses throughout California. They are currently prohibited on elementary school campuses. Existing education code bans the sale of sodas in schools; this legislation would expand that to include sugary drinks.

Click here to read the original SFMS/CMA press release about AB 1746.

Source: California Healthline, February 15, 2013.

The country is in the grip of three emerging flu or flulike epidemics: an early start to the annual flu season with an unusually aggressive virus, a surge in a new type of norovirus, and the worst whooping cough outbreak in 60 years. And these are all developing amid the normal winter highs for the many viruses that cause symptoms on the “colds and flu” spectrum.

Google’s national flu trend maps, which track flu-related searches, are almost solid red (for “intense activity”) and the Centers for Disease Control and Prevention’s weekly FluView maps, which track confirmed cases, are nearly solid brown (for “widespread activity”).

With flu cases in this city up tenfold from last year, the mayor of Boston declared a public health emergency on Wednesday as authorities around the United States scrambled to cope with a rising number of patients.

Health authorities say a virulent strain this year has caused the number of flu cases to surge earlier than usual. Hospitals around the country have scrambled to find additional space to treat the ill, and some have had to turn people away.

The U.S. Centers for Disease Control and Prevention (CDC) reported that the proportion of people visiting their doctors for flu-like illnesses has doubled in the past four weeks.

Encouraging vaccinations is one of the most effective steps in combating what looks to be a serious strain of the flu, said Dr. William Hanage, an associate professor of epidemiology at the Harvard School of Public Health.

The flu season typically picks up in December, builds to a peak in January or February and fades away by late March or early April.

 Flu Information for Health Care Providers

• San Francisco Department of Public Health Health Officer order regarding mandatory influenza vaccination or masking for health care professionals during flu season
• Flu information from the SFDPH Communicable Disease Control and Prevention, including vaccination guide and health alerts
• American Public Health Association's report on early start of flu season, December 4, 2012.
• CDC Report of 2012-2013 Influenza Season Week 52 Ending December 29, 2012.

The Centers for Disease Control and Prevention reported that eight people have died and 105 people in nine states have been sickened by a type of fungal meningitis they were exposed to when they received tainted spinal steroid injections.

According to The Wall Street Journal, as many as 13,000 patients may have been exposed to fungal meningitis from tainted spinal steroid injections. Some lawmakers called for bringing certain specialized pharmacies under greater regulatory scrutiny. The oversight of compounding pharmacies, which create customized versions of medicines, is gaining greater attention as the death and illness tolls in the outbreak continue to rise.

Source: Kaiser Health News