ANTIVIRAL GUIDANCE FOR SUSPECTED, PROABLE,
or CONFIRMED NOVEL H1N1 INFLUENZA

The Centers for Disease Control and Prevention has asked that the following information be disseminated to our membership. It is very important to emphasize early, empiric antiviral treatment for hospitalized patients and high-risk outpatients with suspected, probable, or confirmed novel swine-origin influenza A (H1N1) virus infection.

Preliminary information indicates that some hospitalized patients with novel influenza A (H1N1) virus infection have not been treated with antivirals or that treatment with antiviral agents was delayed until confirmatory testing was completed. In particular, some patients with chest x-ray evidence of pneumonia and influenza symptoms have not received antivirals early. While data from seasonal influenza indicates that early antiviral treatment is most effective (within 48 hours of symptom onset), some studies have reported a benefit in treating hospitalized patients. Therefore, initiating therapy at the earliest possible time is desirable, including at hospital admission, if patients were not previously treated. 

Clinicians should be aware that influenza virus infection can cause primary viral pneumonia and early treatment of people with influenza-related pneumonia is desirable. Additionally, empiric treatment with influenza antiviral medications does not preclude empiric treatment for bacterial co-infections. Specific influenza testing should be performed for any hospitalized patient with suspected novel influenza A (H1N1) virus infection.

The CDC Antiviral recommendations are available at: http://www.cdc.gov/h1n1flu/recommendations.htm. The CDC Testing recommendations are available at: http://www.cdc.gov/h1n1flu/specimencollection.htm.

Accordingly, the CDC emphasizes antiviral treatment for the following:

1. All hospitalized patients with suspected, probable, or confirmed novel influenza A (H1N1) virus infection should be empirically treated with oseltamivir or zanamivir as early after illness onset as possible.

No comparative studies have been done to assess whether higher doses or longer treatment courses might be more effective for severely ill patients. However, a longer duration of treatment should be considered for severe illness that persists at the end of the usual 5 day course. Some experts also recommend higher treatment doses (e.g., 150 mg oseltamivir twice per day), based on concerns about the potential for lower oseltamivir absorption, higher viral loads, and reduced delivery of oseltamivir to damaged tissue among severely ill patients. Patients who have received higher treatment doses or longer treatment durations have tolerated these regimens without substantial increase in adverse events, based on limited data.

1. All outpatients with suspected novel influenza A (H1N1) virus infection who are at higher risk for influenza complications should be empirically treated with oseltamivir or zanamivir as early after illness onset as possible.
2. Groups with a higher risk for influenza complications:
1. Children younger than 5 years old. The risk for severe complications from seasonal influenza is highest among children younger than 2 years old.
2. Adults 65 years of age and older.
3. Persons with the following conditions:
1. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus);
2. Immunosuppression, including that caused by medications or by HIV;
3. Pregnant women;
4. Persons younger than 19 years of age who are receiving long-term aspirin therapy;
5. Residents of nursing homes and other chronic-care facilities.

Additional information can be obtained from the CDC. Should you have any questions, please call the Society office.

PEANUT BUTTER/PEANUT PASTE RECALL

The peanut butter/peanut paste product recall list from the FDA has grown significantly.  These products are being recalled because they are associated with a nationwide Salmonella outbreak and may contain Salmonella Typhimurium bacteria.  Please closely monitor the recall list (which is being updated on a daily basis) at the FDA website.
All recall products should be immediately removed from use and returned to the manufacturer/distributor and/or destroyed. 

IMPORTANT CME UPDATE!!!!!
GOOD NEWS!!!! Cultural Competency CME are available via the Internet!

 The US Department of Health & Human Services Office of Minority Health offers a Cultural Competency CME course on line.  The CME course offers 9 (nine) credits in AMA PRA Category 1. Physicians licensed prior to 2005* (and did not receive instruction in cultural competency training as part of the medical school curriculum)  are required to have 6 (six) CMS credits in Cultural Competency in addition to the 100 credits required by June 30, 2009.

   The web site is: https://cccm.thinkculturalhealth.org/GUIs/GUI_AboutthisSite.asp.

  The Society will have a limited number of CDs available to the membership. Should you wish to have a CD mailed to you, please call the Society office or e-mail us at mcms1816@aol.com. Should you have any other questions, please feel free to call (973) 539-8889.

* If you received your initial New Jersey license after March 24, 2005, the cultural competency training may be included in (instead of in addition to) the CME required.

IMPORTANT NOTICE!!!!

            The State Board of Medical Examiners  regulations on CME for “cultural competency” were adopted and published in the NJ Register on Monday, April 7th.  Six (6) hours of CME will be required by the next biennial registration date of June 30, 2009.  The pertinent part of the regulation states:
            “(d) To be recognized in satisfaction of the cultural competency training requirement applicable to licensees, any CME program of instruction shall be of at least six hours duration, offered in the classroom, or through workshops, over the internet or through other venues, that provides:

1. A context for the training, common definitions of cultural competence, race, ethnicity, and culture and tools for self-assessment;
2. An appreciation for the traditions and beliefs of diverse patient populations, at multiple levels – as individuals, in families and as part of a larger community;
3. An understanding of the impact that stereotyping can have on medical decision-making;
4. Strategies for recognizing patterns of health care disparities and eliminating factors influencing them;
5. Approaches to enhance cross-cultural clinical skills, such as those relating to history-taking, problem solving and promoting patient compliance; and
6. Techniques to deal with language barriers and other communication needs, including working with interpreters.

            (e) A physician who was licensed to practice medicine prior to March 24, 2005*, and who did not  receive instruction in cultural competency training as part of the curriculum of a college of  medicine shall, as a condition of the next renewal after March 24, 2008, document  completion of CME or equivalent post-secondary education in cultural competency training  pursuant to (d) above before being granted licensure renewal by the Board.  Cultural competency training shall be in addition to the CME required by the Board at N.J.A.C.  13:35-6.15.” 

*If you received your initial NJ License after March 24, 2005, the cultural competency training may be included in (instead of in addition to) the CME required, which is 100 hours over a 2-year period; minimum of 40 Category I credits, the remainder in Category I or Category II.

The Institute of Medicine and Public Health of New Jersey (IOMPH), will hold a 3-hour CME course on cultural competency at the Westin Princeton at Forrestal Village on Friday, May 2 from 2:00-5:30pm (prior to the Medical Society of New Jersey convention).  The seminar is free to MSNJ physicians, but registration is required by April 22nd.   Go to the MSNJ website, www.msnj.org for further information and registration form, or call the Society office at (973) 539-8889 and we will fax you a copy of the registration form.

On March 10, 2008, NJDHSS received notification from Virginia Department of Health of a 15 month old unvaccinated child with laboratory-confirmed measles. The child returned to the United States on February 22 after a 2.5-week visit to India. On the return flight (February 21-22) from New Delhi to Newark, New Jersey the child developed fever and cold-like symptoms (rash developed on Feb 25). Upon arrival to Newark airport on February 22, the child and mother traveled out-of-state via a southbound
Amtrak train from Newark train station.

CDC's Division of Global Migration and Quarantine (DGMQ) will ensure that air travelers who were potentially exposed to the child are contacted and informed about recommended precautions. DGMQ will also  follow up with CDC measles experts about how to best contact travelers on the Amtrak train.

Measles typically presents as fever and malaise, cough, coryza, or conjuntivitis, followed by maculopapular rash. Physicians should have elevated suspicion in patient's with a history of travel on Amtrak or through Newark Liberty International Airport in the last 2 weeks. Physicians suspecting measles in any patient are requested to contact the patient's local health department immediately, prior to receipt of
confirmatory laboratory results. Appropriate infection control precautions should be observed.

Contact Info: Elizabeth Handschur, NJDHSS/Vaccine Preventable Disease Program
Phone: 609-588-7520; Email: Elizabeth.Handschur@doh.state.nj.us

ANTI-KICKBACK REGULATIONS ALERT

Concerns have been raised as to the apparent actions of several diagnostic companies in Morris County offering physicians AND THEIR STAFF gifts and or favors (DVD players, theatre/sporting event tickets and other gifts) in return for referrals to their facilities.

ALL MCMS members are alerted to the fact that physicians are expressly prohibited from accepting ANY type of remuneration in return for referrals. More importantly, physicians are also held responsible FOR THE ACTIONS OF THEIR EMPLOYEES. For all MCMS members: Please check with ALL of your staff members immediately and remind them that acceptance of cash/gifts, of any nature, in return for referrals IS EXPRESSLY PROHIBITED BY LAW and will not be tolerated by your practice under ANY circumstances.

Should you have any questions, please call the Society office. .