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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: [email protected]
(*http://www.cdc.gov/flu/weekly/)
Dallas County Health and Human Services DCHHS: [email protected]
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: [email protected]
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: [email protected]
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: [email protected]
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.