How to recognize the novel influenza A among dermatology patients and approaches for handling patients who may be infected while protecting healthy patients in your office or clinic.

Anew strain of the flu is here to stay. H1N1 has been declared a pandemic, and health officials are warily watching what happens in the fall. It has been identified in most countries worldwide, with more than 300,000 cases confirmed and almost 4,000 deaths.1 In the near future, H1N1 will affect the patient population seeking dermatologic care. As such, the dermatology community should be made aware of this pandemic, and a plan should be implemented for dermatology clinics in the event that H1N1 spreads to a greater magnitude.

Overview

The novel influenza A (H1N1) pandemic virus was first identified in April 2009 in Mexico and the United States and quickly spread across the Northern Hemisphere. The virus was genetically characterized as a quadruple reassortant virus originating in swine and containing a reassortment of two previously circulating strains: a “triple reassortant” swine influenza (with gene segments of human, avian and swine viruses) that has been circulating in North America since 1998 and an H1N1 strain that has been circulating for decades in European and Asian swine populations.2 This strain was originally referred to as the “swine flu” and later given proper nomenclature as novel H1N1 influenza (Figure 1).3 Some experts see the emergence of H1N1 has a “herald wave,” a term related to an old hypothesis that describes the inevitable mutation of a virus into a more transmissible and virulent form.4

Symptoms, Diagnosis, and Treatment

Novel H1N1 affects mostly children and young adults under the age of 25. Symptoms caused are similar to the seasonal flu. The usual seasonal flu vaccine offers no protection against Pandemic A (H1N1) virus infection. However, some evidence exists that older populations may have a degree of immunity due to prior exposure to cross-reactive viruses and vaccines.5 When the H1N1 vaccine was released by the CDC in October 2009, priority was given the following high-risk groups: pregnant women, people living with or providing care for infants less than 6 months of age, healthcare and EMS personnel, people between 6 months and 24 years of age, and people between ages 25 to 64 years with chronic conditions such as asthma, diabetes and cardiopulmonary disease.6 Many people will be advised to get both the novel H1N1 and seasonal flu vaccine.

Adults with H1N1 may present with history of subjective fever or temperature <100ºF (37.8ºC) plus one or more flu-like symptoms, such as cough, sore throat, body aches, or sometimes nausea, vomiting, and diarrhea. Children under the age of 6 years may present with fever only. They may not have or be able to describe other flu symptoms.7 Symptom severity can range from mild to severe. Although most cases have resolved without medical treatment, hospitalizations and death have occurred.

Testing for novel H1N1 influenza should be ordered for patients who meet the above criteria, especially those are obese, diabetic or have a history of respiratory disease.8-10 Unfortunately, rapid influenza diagnostic tests (RIDTs) are not effective in ruling out disease.11 Only real-time reverse transcription polymerase chain reaction (rRT-PCR) or viral isolation can confirm the diagnosis in an infected patient. Since definitive diagnosis takes a few days, patients suspected of having H1N1 should be instructed to stay home until fever has resolved for more than 24 hours without fever-reducing medications.

Oseltamivir (Tamiflu) and zanamivir (Relenza) are two medications currently recommended to reduce the severity of H1N1 influenza.12 Notably, H1N1 is resistant to adamantine antiviral medications, such as amantadine and rimantadine. Recommended dosing for treatment and chemoprophylaxis is shown in Table 1.13 The indication for post-exposure chemoprophylaxis is based upon close contact with a person who is a confirmed, probable or suspected case of novel influenza A (H1N1) virus infection during the infectious period of the case.11 Early empiric treatment should be considered in those with suspected or confirmed exposure who have a higher risk of complications, such as children younger than 2 years old, people age 65 years or older, pregnant women, people with chronic immunosuppressive conditions, or people younger than 19 years of age on long-term aspirin therapy.14 Pre-exposure chemoprophylaxis is generally not recommended. Instead, early treatment within 48 hours of exposure is emphasized. Specific situations should be addressed with local public health authorities.

The most common side effect of oseltamivir is nausea and vomiting.15 Rarely, delirium has been reported. Zanamivir is given through an inhaled route and is not recommended for patients with underlying respiratory disease. Due to a lack of reports or evidence about its toxicity, the FDA does not license it for use in children under 7 years of age. However, the FDA has issued an emergency use authorization (EUA), which allows use of oseltamivir and zanamivir in pediatric patients who are sick enough to require hospitalization.16

Recommendations for Outpatient Management of H1N1 in the Dermatology Clinic

Dermatology clinics have a high volume of patients, which makes this setting an environment where disease can spread quickly. Moreover, patient visits are short, and many clinicians may find it unnecessary to take time to screen and isolate patients suspected of having H1N1. Guidelines must be established to facilitate both efficiency in the clinic and safety of patients seeking dermatologic care. We propose the guidelines below and an algorithm is shown in Figure 2.

Inform patients to reschedule if they have fever, cough, or sore throat. This information should be relayed when patients are contacted to remind them of their upcoming dermatology appointment. We suggest the following addendum to the reminder message: “If you have cough, sore throat, fever or other signs of the flu, please do not keep this appointment and call to reschedule for a later date.”

Screen all patients presenting to clinic for flu-like symptoms. This should be done by the triage nurse before the patient encounter with the physician. If the patient affirms any of these symptoms, place a disposable face mask on the patient and take the patient’s vital signs.

If the patient has a fever or other flu-like symptoms, the patient should be advised to schedule an appointment with a primary care physician. The dermatology clinic should have phone numbers readily available for all primary care facilities within that community to ensure timely care.

The patient should be advised to leave with an appropriate disposable face mask after an appointment is made with a primary care physician. Isolation within a dermatology clinic may create unnecessary fear and anxiety.17 Therefore, we do not recommend it. The patient should also be informed of the potential for home isolation by the PCP, which means that he or she will stay home until fever has resolved (<100ºF, 37.8ºC) for at least 24 hours without the use of fever-reducing medications. If the patient works in a healthcare setting or other location where there is high risk of transmission, the patient should stay at home for 7 days after illness onset or after symptoms resolve, whichever is longer.18

Healthcare providers should be educated about a pandemic influenza plan. A recent survey revealed that nearly half of public health employees would be unwilling to report to work during the peak of an influenza pandemic.19 However, nurses and employees who had been educated with pandemic influenza plans were much more willing to respond and report to work. Therefore, healthcare providers must be educated so that they may make a reasonable decision on when to report to work.

Conclusion

Proper education of providers in the dermatology setting will ensure appropriate care of patients who may have H1N1. At the same time, an established plan for management in this scenario will certainly help clinics run efficiently.

Bryant Tran is a medical student at the Wake Forest University School of Medicine, Winston-Salem, NC.

Disclosures: Funding/Conflicts of Interest: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, L.P. The authors have no relevant conflicts of interest to declare.