H1N1 PREPAREDNESS & PLAN Doramarie Arocha Ph.D. Student Walden University PUBH 8165- 10 Dr. Robert Marino Spring 2010 Influenza Preparedness Plan & Infection Prevention Target Audience • • • • Nursing staff Ancillary services Support staff Medical staff Contents • History of Influenza and historical pandemics. • Chain of infection. • Required steps for isolation of influenza patients. • Description of swine flu and seasonal flu. • Importance of an Influenza Preparedness Plan. • Influenza preparedness tools to prevent and/or control an outbreak. • Pandemic Phases • Infection control measures to prevent transmission of infections. LEARNING OUTCOMES At the conclusion of this presentation the participant will: • Explain the process by which a patient is identified as having influenza. • Describe the chain of infection. • Explain the required steps for isolation of influenza patients. • Differentiate between swine flu and seasonal flu. • Discuss the importance of an Influenza Preparedness Plan within the hospital setting and in the community. • List the influenza preparedness tools to prevent and/or control an outbreak. *Including Pandemic Phases • Determine infection control measures to prevent transmission of infections. H1N1 Flu • Swine flu regularly causes outbreaks of influenza in pigs, but human infections have sporadically occurred. • Course of how the virus spreads: – Various species infected by the flu virus – Can infect pigs, swapping genes, forming new viruses – Infect humans who have direct exposure to pigs – Who in turn can infect other humans. Historical pandemics 1918-19 Spanish Flu: An estimated 20-40 percent of the worldwide population became ill. DEATHS: 40-50 million VIRUS STRAIN: H1N1 1968-69 Hong Kong flu: Elderly were most likely to die. DEATHS: 1 million VIRUS STRAIN: H3N2 1957-58 Asian flu: Virus was quickly identified due to new technology. DEATHS: 2 million VIRUS STRAIN: H2N2 2003-09 Avian flu scare: Virus moved from chickens to people. DEATHS: 257 VIRUS STRAIN: H5N1 1977-78 Russian flu: Isolated in China; spread rapidly in children and young adults worldwide. DEATHS: n/a VIRUS STRAIN: H1N1 http:hosted.ap.org/specials/interactives/international/swine flu/index.html Chain of Infection Red Light DX ID High risk patients Staff vaccinations Adherence to policy/procedure Susceptible Host Causative Agent Res er v o ir lo rt a Po it ex of e d Mo y r ent Disinfection, sterilization, and cleaning f Standard and Transmission Based Precautions Mode of Transmission APIC Text Vol. 1 General Principles of Epidemiology 2009 Standard Precautions, Barriers •Guilty until proven innocent or Isolate on suspicion •Flu-like illness •Confirmed flu/Upper & Lower Respiratory Infections •Environmental contamination HOW DOES SWINE FLU COMPARE TO SEASONAL FLU • Swine Flu – influenza A virus – strain that has not been seen before • Seasonal flu – influenza A or B virus – Known variable strains • LIKENESS: • Similar symptoms • Spreads from person to person • Most cases are mild illnesses • Treatable with common antiviral medications. What should an employee do for symptoms of flu? • Notify Occupational Health for: – fever >101 F – new or worsening cough – sore throat – upper respiratory infection • Seek access to care either on campus, or through your primary care physician. • Take precautions for preventing transmission of flu until you are cleared. EMPLOYEES DIAGNOSED WITH INFLUENZA • Notify Occupational Health upon diagnosis. • If no treatment with antiviral medications, then you must stay out of work for seven days. • Do not return to work until you have been without fever for 24 hours even if you have been treated with antiviral medications. What should I do if my patient has flu-like symptoms? • Place a mask on the patient. • Send a throat or nasopharyngeal swab (preferred) for Rapid Flu Testing. • If the Rapid Flu Test is positive for Flu A, the specimen will be sent by the Laboratory to DCHHS for further testing. What should we do to prevent transmission of swine flu? • Practice meticulous hand hygiene and respiratory etiquette. – Cover your cough • tissues • coughing or sneezing into the bend of the arm. – Wash hands or use hand sanitizer • after use of tissues or • any time you get secretions on your hands. • All individuals with flu-like symptoms should wear a mask. • High volume areas (clinics and ER) segregate patients with flu-like symptoms. – CDC recommends a separation of six feet from other patients. • Restrict visitors who may be sick from entering high risk areas. • During flu season: consider getting a seasonal flu vaccination. It may provide some cross protection against other flu strains, including swine flu. Who should wear a mask? • Person’s with flu-like symptoms – including patients, should wear a regular surgical mask. – An N95 respirator mask is indicated during intubation and suctioning of respiratory secretions for a patient with suspected swine flu. Droplet Precautions • Private room preferred or cohort • Surgical mask required for staff and visitors • Surgical mask for patient if transport out of room required Droplet • Used for Bacterial Meningitis , Mumps, Influenza, Pneumonia, Pertussis • Private room • Surgical mask To our patients and visitors: For your safety and the safety of all our patients during this year’s influenza season, the hospital has updated visitation rules. •Visitors under the age of 12 are not allowed in the hospital without special permission from the nurse manager or nurse supervisor. •Only two visitors are allowed in a patient’s room at any one time. Additional visitors may wait in the main lobby of the hospital. •Individuals with flu-like symptoms, including fever or chills or cough or sniffles cannot visit. Please communicate with family and friends that anyone with any of these symptoms may not visit the hospital. We appreciate your understanding and assistance in keeping all patients safe. Thank you. ADDITIONAL FLU PLAN • • • • • • Influenza Plan – IC Policy 205.115 & 205.115A Rapid Flu kits Tamiflu Surgical masks and N95 masks Immunization of Health Care Personnel Future Plans: REDBAT Surveillance What if my patient’s Rapid Flu test is positive for Flu A? • • • • Place in contact and droplet precautions in a private room. A negative air pressure room is preferred, but not necessary. Healthcare workers use a regular surgical mask. Antiviral treatment: Oseltamivir + Rimantadine (may substitute with Amantadine). • Contact Infectious Disease Consult service for patient complications or questions regarding post-exposure or pre-exposure prophylaxis. • Follow-up testing of the specimen will be managed by Microbiology. • Infection Control will report cases to the health department. Screening Tool for Pandemic (H1N1) Influenza Applies to patients, employees, and visitors Step 1: Assess for Influenza-like Illness (ILI) Fever (temp > 38.4°C or 101°F) PLUS ≥ 1 of the following: Rhinorrhea or nasal congestion Cough Sore throat No other alternate explanation of these symptoms Screening Tool for Pandemic (H1N1) Influenza Step 2: If YES then person has an ILI and place standard surgical mask. If patient: triage to appropriate flu assessment area or place in single room for further evaluation. If visitor: recommend they seek their primary care provider if they have mild disease or go to the ER for severe disease If employee: recommend they seek their primary care physician or Occupational Health for mild disease or go to the ER for severe disease Screening Tool for Pandemic (H1N1) Influenza Step 3: Assess severity Shortness of breath Chest pain or pressure Decreased responsiveness or confusion Persistent vomiting, diarrhea, and unable to keep liquids down Worsening headache or seizures Lightheadedness or dizziness Screening Tool for Pandemic (H1N1) Influenza Step 4: Assess risk factors for complications from influenza Children < 5years old Children and adolescents (6 months - 18yo) on long-term aspirin therapy or who might be at risk for experiencing Reye syndrome after influenza virus infection Adults/children with chronic pulmonary (including asthma), cardiovascular (excluding HTN), hepatic, hematological, neurologic, neuromuscular, or metabolic disorders (including diabetes) Immunosuppressed adults/children (including that caused by medications or HIV) Pregnant women Adults > 65 years old Residents of nursing homes or other chronic care facilities Follow-up guidelines after risk-factor assessment: No Risk Factors Yes Risk Factors Mild illness Do not test for flu Do not treat (if no high risk home contacts) Severe Disease Test for flu . Treat per guidelines. Consider ER evaluation or admission. Test for flu. Treat per guidelines. Test for flu. Treat per guidelines. Consider ER evaluation or admission. Please contact infection control with any questions 2009-2010 Influenza Surveillance Program 2010 Influenza A (H1N1) Report CDC Week 14--Week ending April 10, 2010 Epidemiologic Overview for Our County • Low levels of influenza activity continue in our County, with the percentage of positive influenza tests from surveillance sites decreasing markedly to 1.6% during week 14. • Two new hospitalizations of our County residents with confirmed 2009 H1N1 were reported during week 14. Since April 2009, 541 County residents with confirmed H1N1 infection have been hospitalized. About 80% of these patients have had underlying high-risk medical conditions for more severe disease from influenza. • Of the 27 reported H1N1-associated deaths in County residents since April 2009, nineteen (73%) have occurred in persons with underlying high-risk medical conditions. • The 2009 H1N1 influenza virus continues to be the predominant influenza strain currently circulating in Dallas County, comprising 100% of recently subtyped influenza A specimens. A few cases of influenza B have been confirmed in the County. (*http://www.cdc.gov/flu/weekly/) Dallas County Health and Human Services DCHHS: Influenza@dallascounty.org (*http://www.cdc.gov/flu/weekly/) Dallas County Health and Human Services DCHHS: Influenza@dallascounty.org Characteristics of Confirmed Novel H1N1 Cases : April 24, 2009-10 • The majority (86%) of confirmed cases of pH1N1 in this County have been reported in persons 18 years of age and younger. • The median age of confirmed cases is 9 years, with an age range of 1 month to 64 years. • The most frequently reported symptoms among cases have been fever (94%), cough (77%), and sore throat (53%). The average duration of symptoms has been 4.4 days. (*http://www.cdc.gov/flu/weekly/) Dallas County Health and Human Services DCHHS: Influenza@dallascounty.org CDC INFLUENZA SUMMARY CDC FluView report* for Week 14 (April 4 – April 10, 2010) in United States: • There were 2.7% specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories and reported to CDC/Influenza Division were positive for influenza. • Among 34 subtyped influenza A viruses, 33 were 2009 influenza A (H1N1) and one was influenza A (H3). • The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold. • Three influenza-associated pediatric deaths were reported. One was associated with 2009 influenza A (H1N1) virus infection, one was associated with an influenza A virus with an undetermined subtype, and one death was associated with a seasonal influenza A (H1) virus infection, but occurred during the 2008-09. Reference: (*http://www.cdc.gov/flu/weekly/) Dallas County Health and Human Services DCHHS: Influenza@dallascounty.org Pandemic Phases No or very limited transmission Increased transmission 3 6 Significant transmission 4 5 Sustained transmission Imported cases possible Isolation of cases Quarantine of contacts Social Distancing Campaigns Control measures From: DCHHS Pandemic Plan and Cetron, M, CDC 2005. Example of Epidemic: H5N1 poultry outbreak • Largest epidemic in history • Very little cross-over into North American birds Winker K, et al. Emerging Infectious Diseases 2007: http://www.cdc.gov/EID/content/13/ 4/06-1072.htm Vaccine Production • FDA report 2/26/2007, vaccine experimentally effective in 45% of subjects • WHO report 2/16/2007, vaccine production “promising” with more than 40 clinical trials being currently conducted • There are currently 26.2 million doses of vaccine in U.S. Stockpiles • Adjuvants could create >250 million doses 1. Copyright 2007 The Associated Press 2. http://www.who.int/mediacentre/news/n otes/2007/np07/en/index.html 3. Treanor JJ. Clinical Trials of Pandemic Vaccine Candidates. ISDA Seasonal and Pandemic Influenza Conference 2008:Available: http://www.idsociety.org/WorkArea/sho wcontent.aspx?id=11324. ANTIVIRALS • Still currently not recommended to be prescribed by clinicians for the purpose of stockpiling • U.S. has met its goals of stockpiling 81 million courses • Texas has 700,000 courses • Resistance continues to be a concern Non-Pharmaceutical Control Measures • 43 U.S. Cities researched • Early, sustained, layered measures lowered mortality • Isolation/quarantine, school closure, banning of public gatherings • How did our community do? Markel H, et al. JAMA. 2007; 298(6): 644-54 HAND HYGIENE:AN IMPORTANT TOOL FOR PREVENTING INFECTIONS "Handwashing is the single most important means of preventing the spread of infection." CDC • "An estimated 40 million Americans get sick from germs transmitted on dirty hands!" CDC • People not only get sick from the hands to mouth transmission of disease germs, some people die because of these germs! • Quote from USA Today: "As travelers seek ways to ward off germs, manufacturers are happy to oblige with an array of products. But the most effective precaution is the simplest: "Wash your hands." QUESTIONS REFERENCES: 1. Association fro Professionals in Infection Control and Epidemiology (APIC), APIC Text of Infection Control and Epidemiology. Washington, D.C. (2009). 2. Copyright 2007 The Associated Press 3. Dallas County Health and Human Services DCHHS: Influenza@dallascounty.org 4. http:hosted.ap.org/specials/interactives/international/swine flu/index.html 5. (*http://www.cdc.gov/flu/weekly/) 6. http://www.cdc.gov/swineflu/guidance/ 7. http://www.dallascounty.org/department/hhservices/SeasonalInfluenza.html 8. http://www.who.int/mediacentre/news/notes/2007/np07/en/index.html 9. Markel H, et al. JAMA. 2007; 298(6): 644-54 10. Microsoft Office 2007 ClipArt Selection 11. Treanor, JJ. Clinical Trials of Pandemic Vaccine Candidates. ISDA Seasonal and Pandemic Influenza Conference 2008: Available: http://www.idsociety.org/WorkArea/showcontent.aspx?id=11324. 12. Winker K, et al. Emerging Infectious Diseases 2007: Retrieved from: http://www.cdc.gov/EID/content/13/4/06-1072.htm FURTHER READING • Cunha BA. The diagnosis of severe viral influenza A. Infection 2008:36:92-3. • Nelson KE, Master-Williams C. Infectious disease epidemiology theory and practice, 2nd ed. Sudbury, MA: Jones & Barlett; 2007. • Rudnick, SN, et al. Inactivating influenza viruses on surfaces using hydrogen peroxide or triethlene glycol at low vapor concentrations. American Journal of Infection Control (AJIC) 2009; 37:10. • Siegel JD, Rhinehart E, et al. Guidelines for Isolation Precautions: preventing transmission of infectious agents in healthcare settings 2007. Healthcare Infection Control Practices Advisory Committee (HICPAC) Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation 2007. • Centers for Disease Control (CDC). Guidelines and recommendations: infection control guidance for the prevention and control of influenza in acute-care facilities. Available at http://www.cdc.gov/flu/professionals/infectioncontrol/healtcarefacilities.htm.