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Update re Pandemic Influenza and Precautions

Infection Prevention & ControlOccupational Health Hygiene

D. Moralejo PhD, RN; Marion Yetman MN, RN, CIC; Paula March BN, RN et al.

Fall, 2009

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Overview

• The need for this review• Brief background

– How infections occur, breaking the chain– Routine Practices and Additional Precautions

• Seasonal flu and Pandemic (H1N1) 2009– The viruses and disease– Prevention: Clean, Cover, Contain, Choose to be

vaccinated– Management of illness– What to teach others

• Other issues

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The Need for This Review

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The story as it unfolded…

• April 26: 6 cases in Canada: 4 NS and 2 BC • June 11: WHO increases the pandemic alert

level to phase 6

• March 18: first cases in Mexico • April 2 – 60% of La Gloria, Mexico affected• April 17 – 2 cases identified in California• April 23 – Mexico confirms 1000 ill; 40

deaths; 20 H1N1

Edgar #14Y

La Gloria Mexico

• June 11: First lab confirmed cases in NL• Aug 1: > 10,000 cases in Canada• Aug 22: 1441 hospitalizations, 71 deaths

Increased and sustained transmission

H1N1

Pandemic (H1N1) 2009

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Preventing a Repeat of 1918!

1918 was a bad year

We can be better prepared!

What about 2009?

Stuff of novels Just another influenza seasonStuff of novels Just another influenza season

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The Need for This Review

• To be better prepared:– Reinforce good practices– Educate so better decisions are made

• And reassure HCWs, patients and others

• Learning objectives:– Reinforced breaking Chain of Infection– Reinforced RPAP– Understanding of Seasonal and Pandemic

Influenza

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Background:Chain of Infection

• Agent – Bacteria – C. difficile, MRSA– Virus – influenza, norovirus

• Transmission– Contact- norovirus, MRSA…– Droplet – Influenza, RSV,

Pertussis, meningococcus…– Airborne – TB, VZV, Measles

• Susceptible host – No antibody– Reduced WBC or normal

defences

Infectious agent > DefencesInfectious agent > Defences

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Breaking the Chainof Infection: IP&C

• Eliminate agent – Antibiotics or antivirals– Cleaning/disinfection– Remove reservoir

• Stop transmission– Hand hygiene– Protect portals of entry– Reduce carriage on hands and

clothes– Distance/isolation– Contain infectious source

• Reduce host susceptibility– Vaccinate– Improve defences e.g., stop

smoking, nutrition, control diabetes

Applicable for all infections!Applicable for all infections!

Break any link!

PPE

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E.g., Chain of Infection: Influenza

• Agent – Seasonal influenza

virus

• Transmission– Droplet

(cough/sneeze)– Contact with

environment/objects contaminated with respiratory secretions

10From the School of Photographic Arts and Sciences, Rochester Institute of Technology TransmissionFrom the School of Photographic Arts and

Sciences, Rochester Institute of Technology

Droplet

Contact

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Chain of Infection: Influenza

• Agent – Influenza virus

• Transmission– Droplet (cough/sneeze)– Contact with

environment/objects contaminated with respiratory secretions

• Susceptible host – No antibody– Reduced WBC or normal

defences, e.g., age, underlying conditions

Exposure to droplet ≠ transmission ≠ infection!Exposure to droplet ≠ transmission ≠ infection!

The Chain of Infection!One person

can spread the virus to

multiple others

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Susceptible host – No antibody– Reduced WBC or normal

defences

Susceptible host – No antibody– Reduced WBC or normal

defences

Agent Influenza virus

Agent Influenza virus

Transmission– Droplet (cough/sneeze)– Contact with

environment/objects contaminated with respiratory secretions

Transmission– Droplet (cough/sneeze)– Contact with

environment/objects contaminated with respiratory secretions

Eliminate Agent – Clean environment– Antiviral drugs

Eliminate Agent – Clean environment– Antiviral drugs

+

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Influenza: Breaking the Chain

Susceptible host – Vaccinate– Strengthen defences

Susceptible host – Vaccinate– Strengthen defences

Transmission–Droplet: Mask and

Eye Protection–Contact

•Hand Hygiene•Gloves, [Gown]•Distance

Transmission–Droplet: Mask and

Eye Protection–Contact

•Hand Hygiene•Gloves, [Gown]•Distance

Routine Practices and

Additional Precautions

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Background: Routine Practices

System of practices to prevent and control transmission of microorganisms • To protect patients, HCWs and others • Used by all health care workers, for all patients, all

the time, in all health care settings Assumes all blood, body fluids, secretions,

excretions, drainage, tissues of all patients are potentially infective

Behaviors determined by assessment of risk of encountering the above during the patient interaction, not by diagnosis

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Point of Care Risk Assessment

• New term, new emphasis, not new concept!

Prior to each patient Interaction, assess patient and interaction

Is there potential for exposure to secretions via coughing or sneezingor to other blood/body fluids, mucous membranes, non-intact skin or contaminated objects?

Is there potential for exposure to secretions via coughing or sneezingor to other blood/body fluids, mucous membranes, non-intact skin or contaminated objects?

What other risks for transmission are there?What other risks for transmission are there?

What PPE do I need?What PPE do I need?

What other actions are required?What other actions are required?

What is the need for hand hygiene?What is the need for hand hygiene? Is ABHR/a sink available?Is ABHR/a sink available?

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Hand Hygiene PPE Respiratory hygiene/ cough etiquette Patient placement/ accommodation Patient flow/activity Cleaning/disinfection

of patient equipment

Hand Hygiene PPE Respiratory hygiene/ cough etiquette Patient placement/ accommodation Patient flow/activity Cleaning/disinfection

of patient equipment

Cleaning of environment

Handling of waste, linen and dishes

Management of visitors Aseptic technique Sharps safety

Cleaning of environment

Handling of waste, linen and dishes

Management of visitors Aseptic technique Sharps safety

RP Helpful for Influenza

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RP vs AP

Routine Practices:• Disrupt chain of infection for influenza• Assume everyone carries something so use

interventions if possibility of being exposed

But with a known or highly suspect infection, probability of exposure is high so definitely need to use interventions!

Additional = Transmission-based Precautions “Pre-packaged” based on mode of transmission and

interruption of transmission Contact, Droplet, Droplet/Contact, Airborne, (Airborne/Contact)

AP for Seasonal Influenza

Seasonal Pandemic

Droplet Precautions•Mask/eye protection within 2 metres of pt

Contact Precautions•Gloves for contact with pt or environment•Gown if likely to be soiled with resp. secretions

Hand hygiene

Other

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√ √

√ √

√ √N95 for selected AGMP

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Eye Protection

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Overview

• The need for this review• Brief background

– How infections occur, breaking the chain– Routine Practices and Additional Precautions

• Seasonal flu and Pandemic (H1N1) 2009– The viruses and disease– Prevention: Clean, Cover, Contain, Choose to be

vaccinated– Management of illness– What to teach others

• Other issues

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Influenza Viruses

• Families: A, B, and C– Multiple strains

• Variants for humans, birds, pigs…– Animal/bird strains do not

usually infect humans

• 2 spike proteins on its surface: H and N– 16 different

haemagglutinins – 9 different neuraminidases

Eg: A/Brisbane/10/2007 (H1N1)Eg: A/Brisbane/59/2007 (H3N1)

Pandemic strain 2009:Unusual mix of swine,

avian and human influenza

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S&S of Seasonal Flu• Fever > 38º

– May not be prominent in elderly• Cough• Sudden onset • 1 of: Fatigue, sore throat, headache,

muscle & joint pain

• Flu is a respiratory infection!– But children <5 years may have GI

symptoms--diarrhea and vomiting • Range: mild to severe illness

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A Word About Influenza-Like Illness (ILI)

Multiple viruses cause similar S&S!

Clinical dx based on what is circulating--need to test to know what causative agent is

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Why Worry About Seasonal Influenza?

• Up to 10-25% of population ill in season• Per year, in Canada, flu or its

complications causes:– Average of 4000 deaths [6000-8000*]– 20,000 hospitalizations [30,000-40,000*]– Most severe in very old and very young

Note: most influenza deaths and cases are not recorded!

*in more severe seasons

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Seasonal and H1N1: Similarities

Seasonal Pandemic (H1N1) 2009

S&S Similar Similar*

Transmission Droplet/Contact Droplet/Contact

Incubation 2 days 7 days

Period of communicability

5 days 7 days

Where spread 1° Community 1° Community

* But younger people affected, also certain populations: aboriginal, obese persons & pregnant women--ARDS in severely ill

• Novel virus – NO immunity– Except >60 years

• Two or three times a century• Two waves

– Several months apart– Each lasts 2 or 3 months

• 35 % or more affected– Healthy adults

• Vaccine not available for up to 6 months after novel virus identified

• Anti-virals – may be in short supply

• Novel virus – NO immunity– Except >60 years

• Two or three times a century• Two waves

– Several months apart– Each lasts 2 or 3 months

• 35 % or more affected– Healthy adults

• Vaccine not available for up to 6 months after novel virus identified

• Anti-virals – may be in short supply

Seasonal InfluenzaSeasonal Influenza Pandemic InfluenzaPandemic Influenza• Some immunity from prior

exposure to similar viruses

• Happens every year

• Usually from Jan – April & stops

• 10-25% of pop affected• Very young and old

• Vaccine available pre-season which offers protection

• Anti-virals available

• Some immunity from prior exposure to similar viruses

• Happens every year

• Usually from Jan – April & stops

• 10-25% of pop affected• Very young and old

• Vaccine available pre-season which offers protection

• Anti-virals available

Seasonal and Pandemic: Differences

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Preventing influenza: 1918 versus 2009 public health messages

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Shared Responsibility

• Screening protocols• Source Control

– Adequate space and plexiglass (separate ILI pts)

– Signs, ABHR– Accommodation

• Environmental control– Housekeeping

• Air exchanges• HCW Dx and Rx

– Antiviral drugs

• Vaccination programs

• Point of care risk assessment/ screening

• Hand hygiene• Droplet/Contact

Precautions• Teach/facilitate cough

etiquette

• Self screening• Vaccination

OrganizationalOrganizational HCW: Direct CareHCW: Direct Care

HCW: OtherHCW: Other

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Contain

Cover

Clean

Simplifying the Messages

• Clean

• Cover

• Contain

Cho

ose

to b

e

vacc

inat

ed !

• Charge up your defences–Choose to be vaccinated!

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1. Contain

Contain Spread/Illness– Screen for illness– Maintain distance

• Stay home if ill

Contain Spread/Illness– Screen for illness– Maintain distance

• Stay home if ill

Screening at entry:• Ambulance calls• ILI pts in clinics/ER• Signs directing pts to right

area, respiratory hygieneScreening inpatients,

visitors /companion: Screen for change: new ILI

Distance

• 2 metres between ILI pts

• Designated areas for ILI pts

• Plexiglass, curtains etc.

Permits timely application of Droplet/Contact Precautions and appropriate accommodation

Report to IP&C any patient with ILI symptoms!

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Contain: More on Screening

• Screening criteria– Abrupt onset of:

• Fever (>380) or • New onset or worsening of existing cough; and• Any of the following: headache, sore throat, joint

pain, muscle pain or severe fatigue

• Screen patients, and don’t forget visitors and companions

• HCWs: Self-assessment prior to arriving in the workplace

New or worsening cough or

SOB?

ILI Screening

Fever or chills in past 24

hrs?

Yes

Yes

Initiate Droplet and Contact Precautions

and continue assessmentMaintain until diagnosis confirmed or ruled out

RPNo

Yes

Yes

No Fever or chills in past 24

hrs?

NoNoHeadache, sore throat

joint or muscle

pain, severe fatigue?

1 of:

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Accommodation– Single room or cohort– Droplet-Contact Sign on

door– Confine patient to room

• Outside room – patient wears surgical mask

• Respiratory hygiene must be practiced

•Self isolate at home

In ER/Assessment Clinics–Partitions in triage areas–Post signs–Provide masks–Provide ABHR–Provide hand free garbage receptacles

–Remove magazines and toys from waiting areas

More about “Contain”

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2. Cover

• Coughs – Everyone to use respiratory hygiene/ cough

etiquette: Self and teach patients/ others – Cover cough/sneeze with tissue or sleeve– Discard tissue– Hand hygiene after!– Need signs, ABHR, tissues, hands-free

garbage receptaclesDroplet Precautions!• Nose/mouth and eyes of HCWs

– Wear a surgical mask and eye protection!•Within 2 metres of coughing patient

• Patient to wear surgical mask outside room

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Cover: Masks, not N95s?

• Surgical mask for Droplet Precautions• N95 respirator is used for aerosol-generating medical

procedures (AGMPs) if pt has TB or SARS or suspected novel influenza virus – E.g., endotracheal intubation, bronchoscopy,

respiratory/airway suctioning and resuscitation– List as per PHAC web site – Recommendations change as knowledge evolves– Use respirator as per fit test

Inappropriate and widespread use of N95 respirators

– Has negative health effects for HCW

– Will reduce supplies so not available when needed

Inappropriate and widespread use of N95 respirators

– Has negative health effects for HCW

– Will reduce supplies so not available when needed

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More to Cover!

• HCW hands– Wear gloves when in direct contact

with patient or patient’s environment

• HCW clothes– Wear gown if anticipate clothes will come in

contact with respiratory secretions

Perform hand hygiene immediately after removal of PPE and immediately after exit from patient environment!

Perform hand hygiene immediately after removal of PPE and immediately after exit from patient environment!

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3. Clean

• Hands– ABHR or soap and water– Frequently! As per RP but especially…

• Before touching mucous membranes• After contact with respiratory secretions or environment

contaminated with secretions

• The environment– at least daily or more often, depending on extent of

contamination

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Clean, Cover, Contain…Charge!

Charge up defences• Choose to be vaccinated• Strengthen normal

defences

• Seasonal flu vaccine• Pandemic flu vaccine• Pneumococcal

vaccine – If > age 65 or high risk

Strengthen normal defences:• Stop smoking• Stay hydrated, well-nourished• Control diabetes

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Choose to beVaccinated!

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• NL DOHCS provides vaccine for:– Infants >6 – 23 months– >65 years– Persons-medical conditions– Health care workers– Emergency responders– Care givers of high risk

individuals– Pregnant women

• NL DOHCS provides vaccine for:– Infants >6 – 23 months– >65 years– Persons-medical conditions– Health care workers– Emergency responders– Care givers of high risk

individuals– Pregnant women

• Three components–Two influenza type A–One type B

• Reconfigured annually–Decision of WHO based on

FluNet

• 2009-2010 Vaccine• A/Brisbane/59/2007(H1Ni)• A/Brisbane/10/2007(H3N2)• B Florida/4/2006-like virus

• Three components–Two influenza type A–One type B

• Reconfigured annually–Decision of WHO based on

FluNet

• 2009-2010 Vaccine• A/Brisbane/59/2007(H1Ni)• A/Brisbane/10/2007(H3N2)• B Florida/4/2006-like virus

Seasonal Influenza Vaccine

LTC > Acute

Only 10-60% of

HCWs get vaccinated

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Pandemic Influenza Vaccine

• Production underway– Available in late fall 2009– Seasonal vaccine confers little or no protection

against novel virus

• Safety– Licensed vaccines held to high level of safety– Close monitoring and investigation of all adverse

events

• Priority for vaccine– Decision of national authorities

• Mass vaccination campaigns required!

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Why Get Vaccinated?

Health care workers are at a higher risk of getting and transmitting the influenza virus because the nature of their work places them in close contact with a high risk group of patients

BUT…HCWs are also at risk of acquiring the influenza virus in the community—the same as everyone else!

E.g. in stores, on the bus, at hockey games…

Getting vaccinated protects the HCW, their families and their patients

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Impact of Influenza Vaccine

• Pre-exposure immunization is the most efficient method to decrease “flu” outbreaks

• Experience with seasonal influenza vaccination– 70% - 90% effective in preventing illness in healthy adults– Prevents serious illness and death in all age groups– In older age group

• 50 – 60% effective at preventing hospitalizations• 80% effective at preventing deaths

– Preventing illness in HCWs prevents illness in patients!

• Both seasonal and pandemic strain vaccines will be available in Fall 2009

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The flu shot doesn’t workThe flu shot doesn’t work

I never get sick so don’t need itI never get sick so don’t need it

Flu vaccine causes the fluFlu vaccine causes the flu

20% have few S&S but still pass the virus to others20% have few S&S but still pass the virus to others

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Myths About the Flu Vaccine

70-90% effective when good match70-90% effective when good match

Contains dead virus – cannot cause fluContains dead virus – cannot cause flu

I’m pregnant and shouldn’t get the vaccineI’m pregnant and shouldn’t get the vaccine

Flu vaccine is safe during pregnancy and is recommended

Flu vaccine is safe during pregnancy and is recommended

Getting the vaccine weakens your immune systemGetting the vaccine weakens your immune system Vaccine prepares and

boosts your immune system against the virus

Vaccine prepares and boosts your immune system against the virus

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HCWs Also Say They Don’t Get Vaccinated Because…

I don’t like needles!

It will give me a headache, sore arm, slight fever,

ache…

Benefits > Discomfort!

Acetaminophen reduces incidence

and severity of side effects!

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To Vaccinate or Not?

• If take it when offered– Have resistance before exposure

• If wait to take it when outbreak in work setting:– 14 days for antibodies to develop!– You may get sick and may not be able to work

• If refuse vaccine and rely on treatment or avoidance or other strategy:– You may get sick and may not be able to work

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Duty of Care

Health care workers and health care systems have an ethical and moral duty to protect vulnerable patients from transmissible diseases

Yet HCW vaccination rates are low! What else

do we need to do to get

HCWs vaccinated?

• Vaccinate self

• Encourage others and facilitate access

• At minimum, do not discourage others!

Make mandatory? Declination forms?

More educationEasier access

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Putting It All Together

• Contain– Screen– Distance

• Cover– Cough– Nose/mouth– Hands– Clothes

• Clean– Hands– Environment

Routine Practices• For all patients!

Additional Precautions• Droplet and Contact for ILI

• Choose to be vaccinated

Charge up defences

For now, same precautions for seasonal and pandemic strains

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More on AP for Flu This Season

• Same precautions regardless of strain– But situation may change as virus or

pandemic evolves

• Risk assessment tools available to help identify risk given patient condition and interaction and PPE to use

Don’t self-contaminate when removing PPE!

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Overview

• The need for this review• Brief background

– How infections occur, breaking the chain– Routine Practices and Additional Precautions

• Seasonal flu and H1N1– The viruses and disease– Prevention: Clean, Cover, Contain, Choose to be

vaccinated– Management of illness– What to teach others

• Other issues

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Management of Illness

• Get lots of rest• Drink lots of fluids

– Feed a fever and feed a cold!

• OTCs and complementary medicine– No evidence of value for influenza

• Stay home until symptoms resolved and able to resume normal activities– Longer if cough not resolved

• Antiviral drugs not for everyone• For further info: see PHAC, NL and MUN websites

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ILI in the Home

• Person with ILI should self isolate until symptoms resolved– Try to remain 2 metres from others– Dedicate room, bathroom, towels etc if possible– Enhance hand hygiene practices/general cleaning

practices– Do not need to have a NP swab done or see MD if mild

illness– Promote rest, fluids, pain relief etc…

• Others in the home or contact with ILI case:– Can go to work– Must self assess for ILI symptoms

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Antiviral Drugs

• Tamiflu (oseltamivir) & Relenza (zanamivir)– Both effective against H1N1 Influenza A– Usual Adult Treatment

• Tamiflu – Adult - 75 mg BID x 5d (over 1 y)• Zanamivir – Adult – 10 mg Bid x 5 days (over 7)

• Treatment recommended for:– Severe cases & moderately severe cases with risks, as for

routine influenza– Pregnant women with ILI in 2nd or 3rd trimester or within 4

weeks post-partum

• Prophylaxis and treatment recommended for:– Outbreaks in closed facilities

Over use can lead to resistance!

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Prevent flu in yourself! Clean & Choose

Prevent flu in others!Cover & Contain

Check yourself for ILI S&S

Clean,Cover, Contain, Choose to be

vaccinated

What to Teach Others

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• Contain– Screen– Distance

• Cover– Cough– Nose/mouth– Hands– Clothes

• Clean– Hands– Environment

Routine Practices• For all patients!

Additional Precautions• Droplet and Contact for ILI

• Charge up defences– Vaccinate

For now, same precautions for seasonal and pandemic strains

Take Home Messages

Break the chain of infection!

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Credits

Infection Prevention & ControlOccupational Health Hygiene

Narrated by: Dr. Donna Moralejo

Written by: Dr. Donna Moralejo, Marion Yetman and Paula March, in consultation with:•The Provincial Pandemic Infection Prevention & Control/Occupational Health Hygiene Action CommitteeEastern Health: Donna Ronayne & Ada FowlerCentral Health: Penny Ralph & Shelley WoolfreyWestern Health: Paula Price & Jackie YoungLabrador-Grenfell Health: Paula March & Lorraine Mitchell

Funding provided by:The Department of Health and Community Services, Newfoundland Labrador

Produced by: Distance Education and Learning Technologies© Dr. Donna Moralejo and Marion Yetman 2009

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Thank you! Any Questions?