2009 H1N1 PANDEMIC UPDATE FOR EMS_________________________

Alexander L. Brzezny, MD, MPHGrant County Health Officer

____________Jackie Dawson, PhD

Public Health Epidemiologist

TOPICS What you may not know about influenza A Caring for patients: suspect, probable and

confirmed influenza EMS-specific guidance /recommendations Personal Protective Equipment (PPE) use Triage protocols for pandemic flu surge Vaccine and antiviral medications use Healthcare workers & 2009-10 flu season

H1N1 control: Four numbers

6 (feet of separation)100 (Fahrenheit)7 (days of exclusion)24 (hours w/o fever)

ILI=Influenza-Like IllnessInfluenza-like illness (ILI):

Fever>100F (37.8C) ANDCough AND/OR Sore Throat Absence of other obvious known cause

Influenza (flu) is caused by a virus that spreads easily by coughing and sneezing. Close contact within 6 feet. Can be transmitted by surfaces.

Influenza is a Respiratory Illness

“Swine” Influenza virus

.08 -.12 microns

Staph aureus 1 micron

Social DensitySocial Density

http://buildingsdatabook.eren.doe.gov/docs/7.4.4.xls

12 feet 3-4 feet

8 feet

Elementary Schools

Hospitals

Offices

16 feet

Residences

People spacing: If homes were like schools

*Based on avg. 2,600 sq. ft. per single family home

Source: WHO

Swine Influenza A(H1N1) Transmission Through Species

Avian Virus

Human Virus

Swine Virus

Avian/HumanReassorted Virus

Reassortment in Pigs

Novel H1N1 Influenza The virus contains

gene segments from FOUR different influenza types: North American swine North American avian North American human Eurasian swine

Rate & number (in parentheses) of hospitalized or fatal cases of PanH1 influenza by county, 2009 (n=119)

Clallam (1)

Grays Harbor

(1)

Pacific

Cowlitz*

Clark (4)

Island (1)

King (60)

Lewis*

Mason (3)

Pierce (22)

Skagit*

Snohomish (11)

Thurston (5)

Whatcom (1)

Adams

Benton (1)

Chelan*

Columbia

Franklin Garfield

Grant (3) Kittitas*

Klickitat

Lincoln

Okanogan

Spokane*

Walla Walla

Whitman*

Yakima (1)

Douglas*

Ferry

Stevens

Pend Oreille

Asotin* Skamania

Wahkiakum

Jefferson* Kitsap

(7)

San Juan

*Reported non-hospitalized PanH1 influenza case(s)

Rate per 100,000:

0.1-1 1.1-2

2.1-3 3+

0

H1N1 SURVEILLANCE Infectious period for a confirmed case of 2009

H1N1 infection: 1 day prior to the case’s illness onset to 7 days after onset (or 24 hours after fever gone).

Close contact: within about 6 feet of an ill person who is a confirmed or suspected case of 2009 H1N1 (swine flu) virus infection during the case’s infectious period

H1N1 SURVEILLANCE Suspect H1N1 case: a person with an

influenza-like illness (ILI) Probable H1N1 case: a person who meets

the suspect case definition and who is positive for influenza A

Confirmed H1N1 case: a person with ILI and laboratory-confirmed novel influenza A (H1N1) infection by one or more of the following tests: Real-time RT-PCR Viral culture

H1N1 SURVEILLANCE MANDATORY REPORTING CHANGE Healthcare workers and hospitals should

IMMEDIATELY report the following patients to public health: Hospitalized patients with laboratory-confirmed*

(not “suspected”) influenza infection, Deceased patients with laboratory-confirmed*

influenza infection, and Deceased patients suspected to have influenza

infection.

*a positive rapid influenza test, PCR test, direct or indirect fluorescent antibody, or viral culture

H1N1 SURVEILLANCE If testing for 2009 H1N1 virus has not

been performed, laboratories should submit clinical specimens or viral isolates to PHL (public health lab) within 72 H of collection from: Deceased or critically ill patients (i.e., ICU

admission) suspected to have influenza. Hospitalized patients who have tested positive for

influenza. Option to submit specimens from non-hospitalized

pregnant women who have tested positive for influenza.

www.doh.wa.gov/ehsphl/Epidemiology/CD/swineflu/sflu-testalg.pdf

2009 H1N1- September, 2009Total WA 2009 H1N1 Flu Hospitalizations and

DeathsPosted September 11, 2009, 1:00 PM PT

Total WA Novel H1N1 Flu Hospitalizations

164Total U.S. Novel H1N1 Flu Deaths

16

Novel H1N1 vs. Seasonal Influenza Differences between the novel H1N1

and the seasonal flu variety: It is capable of multiplying deep within the lungs. High viral load in the upper airways. Attack rate of 35-40% in close contacts (vs. 5%) The immune system does not know it: lung

damage more severe in those severely ill. Most severe cases and deaths are occurring in

people below 50 years of age (88%). Projected to cause additional 30,000 - 90,000

deaths in 2009-2010.

Duration of hospital stay among hospitalized persons with 2009 H1N1 influenza* (Washington)

*Incomplete reports on 43 cases

1

13

30

97 7

5

0 0 0

4

0

5

10

15

20

25

30

35

0 1 2 3 4 5 6 7 8 9 10+

Length of stay (days)

Nu

mb

er o

f ca

ses

23.5 25.2

33.6

17.611.3

57.1

28.6

3.0

0

10

20

30

40

50

60

0-4 5-17 18-49 50+

Age group (years)

Per

cen

tag

e o

f P

anH

1 ca

ses

Hospitalized or fatal (n=119) Non-hospitalized (n=532)

p<0.001

All 2009 H1N1 cases by age group & hospitalization status

Symptoms of hospitalized/fatal cases of 2009 H1N1 influenza (Washington)

Hospitalized or Fatal

Symptoms (n*) Symptom Present %

Fever (111) 105 95

Cough (111) 105 95

Shortness of breath (70) 49 70

Sore throat (69) 35 51

Vomiting (90) 35 39

Diarrhea (90) 23 26

* Number of records where presence or absence of symptom specified

Pre-existing conditions in hospitalized or fatal 2009 H1N1 influenza (Washington)

Hospitalized or Fatal(N=111*)

Condition n %

Lung diseases/conditions 39 35 Asthma 24 22

Smoking 11 10

Chronic lung disease 9 8

Diabetes 16 14

Heart disease 14 13

Steroid therapy 8 7

Pregnancy 6 5

Chemotherapy/cancer in last year 5 5

*6 incomplete or missing case reports, 2 case investigations in progress

Clinical findings in hospitalized or fatal 2009 H1N1 influenza (Washington)

Hospitalized or Fatal

Clinical condition (n*) Present %

Pneumonia (95) 47 50

Hypoxia (77) 34 44

ICU admission (107) 33 31

Mechanical ventilation (32) 23

Adult respiratory distress syndrome (25) 17

Received antiviral medication (104) 81 78

* Number of records where presence or absence of condition specified

Washington 2009 H1N1 Summary 39% of hospitalized/fatal cases reported

vomiting compared to 25% of non-hospitalized cases.

74% of hospitalized cases had a pre-existing condition compared to 22% of non-hospitalized cases.

More hospitalized cases were pregnant or had asthma, chronic lung disease, diabetes, heart disease, steroid therapy, chronic kidney disease, cancer or chemotherapy in the preceding year.

H1N1 is now endemic in Grant County and is causing regional epidemics in WA

Influenza high-risk individuals Pregnant women, People with asthma and other lung disease, Diabetics, Morbidly obese person, People with blood disorders (sickle cell, etc.) People with compromised immune systems, People with heart disease, stroke or similar, Those with neuromuscular diseases (CP, etc.), Hemodialysis patients (and other ESRD), Infants, elderly, nursing home residents, Individuals with a recent illness.

Stop the spread of 2009 Influenza viruses

9/12/2009 CDC

Recommendations for EMS and Medical First Responder Personnel Including Firefighter and Law Enforcement First Responders

For purposes of this section, “EMS providers” means pre-hospital EMS, Law Enforcement and Fire Service First Responders.”

http://www.cdc.gov/h1n1flu/guidance_ems.htm

Recommendations for 9-1-1 Public Safety Answering Points (PSAP) PSAP to question callers and ascertain:

Is anyone at the incident location afflicted by the swine-origin influenza A (H1N1) virus:

to communicate the possible risk to EMS personnel prior to arrival, and

to assign the appropriate EMS resources. PSAPs should review existing medical dispatch

procedures and coordinate any modifications with their EMS medical director and in coordination with public health.

Recommendations for 9-1-1 Public Safety Answering Points (PSAP) PSAP should screen all callers for any

symptoms of acute febrile respiratory illness.

Callers should be asked if they, or someone at the incident location, has fever, cough, sore throat, shortness of breaht, nasal congestion, or other flu-like symptoms. If the PSAP suspects ILI, they should make sure

any first responders and EMS personnel are aware of the potential for “acute febrile respiratory illness” or “ILI” before the responders arrive on scene.

Scene Safety Address scene safety:

If PSAP advises potential for acute febrile respiratory illness symptoms on scene, EMS personnel should don PPE PRIOR TO ENTERING SCENE

If PSAP has not identified any ILI individuals, EMS personnel should stay more than 6 feet away from patient and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of influenza.

All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient.

Scene Safety Assess all patients for symptoms of

acute febrile respiratory illness (fever plus one or more of the following: sore throat, or cough, possibly rhinorrhea). If no symptoms of acute febrile respiratory

illness, provide routine EMS care. If symptoms of acute febrile respiratory illness,

don appropriate PPE for suspected case of swine-origin influenza if not already on.

Report information about any ILI patients to the patient transport destination

Current WA State recommendations for use of PPE for HCW and EMS EMS workers should put on a mask when

attending to a patient with influenza-like illness.

When splashing or contact with respiratory fluids is likely or when close contact is expected as when caring for an infant, EMS caring for patients with influenza-like illness should use gown, gloves, and face protection (mask and goggles or faceshield).

Before and after contact with the patient, clean hands thoroughly with soap and water or an alcohol-based hand gel.

Current WA State recommendations for use of PPE for HCW and EMS For cough-inducing or aerosol-generating

procedures in patients with influenza-like illness, healthcare personnel should use either a respirator (e.g. N95) and eye protection (or PAPR). Such procedures include: nebulizer treatments trachostomy care suctioning bronchoscopy intubation post-mortem examination

While collecting respiratory specimens, an N95 respirator would be preferred but, if not available, a tightly fitting mask with eye protection is acceptable.

Surgical masks Easily available and commonly used for routine surgical and

examination procedures High-filtration respiratory mask (i.e. N95)

The masks have numbers beside them that indicate their filtration efficiency. For example, a N95 mask has 95% efficiency in filtering out particles greater than 0.3 micron under normal rate of respiration.

The next generation of masks use Nano-technology which are capable of blocking particles as small as 0.027 micron.

Types of Protective Masks

Types of Protective Masks Small facemasks are available for children:

problematic to be worn correctly and consistently.

no facemasks (or respirators) have been cleared by the FDA for use by children.

PAPR (Powered Air Purifying Respirator)

Current WA State recommendations for use of PPE for HCW and EMS Healthcare facilities should plan for allocation of

personal protective equipment, including masks and N95 respirators.

Respirators should be used in accordance with Occupational Safety and Health Administration (OSHA) regulations. Staff should be checked for medical contraindications.

In addition, staff should be fit-tested and trained for respirator use (WAC 296-842, OSHA 1910.134) including proper fit-testing, use, safe removal, and disposal of respirators (www.fda.gov/cdrh/ppe/masksrespirators.html)

How to Reduce Respiratory Droplet Exposure? Standard droplet respiratory precautions will

significantly reduce the transmission of respiratory illness.

Consider Metered Dose Inhaler (MDI) rather than a nebulizer, supra-glottic adjunct airway devices verses intubation (Combitube or King Airways), and HEPA filters on bag-valve-mask devices or any Oxygen delivery systems (as available).

Encourage good patient compartment vehicle airflow/ventilation to reduce the concentration of aerosol accumulation when possible.

At The Receiving Facility Routinely assess all persons entering a receiving

facility and offer a mask to those with cough or respiratory symptoms if already not on.

Assess incoming patients in a location with negative pressure air handling if feasible.

Assure provisions for prompt isolation and assessment of symptomatic patients.

Place patients with influenza-like illness in a private room with a closed door, or cohort patients with influenza-like illnesses if private rooms are unavailable.

Have patients with influenza-like illness wear a mask when outside their hospital room, or use tissues to cover coughs and sneezes if mask use is not possible.

At The Receiving Facility Place patients with suspected or confirmed 2009

H1N1 infection, especially those who require frequent aerosol-generating procedures, in an airborne infection isolation hospital room (6-12 air changes per hour), if available.

Emphasize hand hygiene before and after patient care, after removing personal protective equipment (including gloves), and after any contact with respiratory secretions.

Limit healthcare workers entering the room of a patient in isolation to those performing direct patient care.

Healthcare workers should put on a mask when entering the room of a patient with influenza-like illness.

After Response /Transportation Perform a thorough cleaning of the stretcher and

all equipment that has come in contact with or been within 6 feet with an approved disinfectant, upon completion of the call.

Stretchers, railings, medical equipment control panels, adjacent flooring, walls, ceilings and work surfaces, door handles, radios, keyboards and cell phones, etc.

After the patient has been removed and prior to cleaning, the air within the vehicle may be exhausted by opening the doors and windows of the vehicle while the ventilation system is running (away from pedestrian traffic).

After Response /Transportation Large spills of bodily fluids (e.g., vomit) should first

be managed by removing visible organic matter with absorbent material.

Place contaminated reusable patient care devices and equipment in biohazard bags.

Clean and disinfect non-patient-care areas of the vehicle according to the vehicle manufacturer’s recommendations.

Cleaning should be done with detergent and water and then disinfected using an EPA-registered hospital disinfectant in accordance with the manufacturer's instructions.

www.flu.gov/professional/hospital/cleaning_ems.html

Source: Bean B, et al. JID 1982;146:47-51

Survival of Influenza Virus Surfaces and Affect of Humidity &

Temperature* Hard non-porous surfaces 24-48 hours

Plastic, stainless steel Recoverable for > 24 hours Transferable to hands up to 24 hours

Cloth, paper & tissue Recoverable for 8-12 hours Transferable to hands 15 minutes

Viable on hands <5 minutes only at high viral titers Potential for indirect contact transmission

*Humidity 35-40%, Temperature 28C (82F)

After Response /Transportation Health care personnel, public health workers, or

first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person’s infectious period should be considered for antiviral chemoprophylaxis with either oseltamivir or zanamivir. (www.cdc.gov/h1n1flu/recommendations.htm)

EMS and Healthcare Workers should be monitored daily for signs and symptoms of influenza-like illness.

Ill EMS and HCW’s should be excluded from work for 7 days, or until 24 hours after symptoms resolve, whichever is longer.

No further follow-up

Yes

No

Assessment Flow Chart

Temp is >100.4o F. and

you develop any of the first4 symptoms of diary

- Notify Employee Health Service- Fill out "Employee Incident Report"- Stay home & report illness to \ Staffing Office or supervisor

Note: The infectious period for H1N1 flu is one day before symptom onsetuntil seven days after the patient's

onset of illness. If close contact occurred with a case whose illness started more than 7 daysbefore contact, then prophylaxis is not necessary.

No

Yes

Limited Exposure

- Wore mask during patient care- Transported patient- Cared for patient but did not have close or prolonged contact with patient's aerosolized oral secretions

Less than 7 dayssince exposure

NoNo furtherfollow-up

Yes

* Receive Prophylaxis

Self-monitor for "Influenza-like Illness" symptoms for 7 days

after limited exposureusing "Symptom Diary" (page 3)

H1N1 Influenza Virus ExposureFor use with exposure to patients/individuals with suspected or confirmed H1N1 Influenza only.

* PAPR = purified air particulate respirator.

Complete Patient Information Profile (page 2 of this policy) and

Complete Employee Incident Report &see Emergency Department Physician

Close Contact Exposure(with no mask/PAPR* & within 6 feet of patient)

Directly exposed to patient's aerosolizedsecretions by endotracheal intubation,

suctioning, ET tube management, oral suctioning,or directly to patient's cough or sneeze.

Effect of Prehospital and other Community Interventions1. Delay disease transmission and outbreak peak

2. Decompress peak burden on healthcare infrastructure3. Diminish overall cases and health impacts

DailyCases

#1

#2

#3

Days since First Case

Pandemic outbreak:No intervention

Pandemic outbreak:With intervention

Summary of pre-hospital interventions Before moving closer than 6 feet, Use PPE for respiratory droplet precautions (a

mask, fit-tested N95 respirator when appropriate, disposable gloves, gown, and eye protection).

Place a mask on the patient. After contact with the patient clean hands

thoroughly with soap and water or an alcohol-based hand gel.

After caring for the patient cleanse the vehicle for respiratory droplet contamination.

Sample triage forms Employee exposure form SORT Adolescent-Adult triage Kaiser Permanente Colorado CDC triage forms still preparation

SORT triage evaluation (KPCO)

Risk GroupNumber of

Clinic Visits

Related Hospitalization

s Within 14 days

Rate of Hospitalizations within 14 Days

Elevated 573 30 5.2%Intermediate 645 8 1.2%Low 1540 2 0.1%

Unique people per risk group using the CDC definition of symptoms Fever ( by VS temp or complaint) + one Sore Throat or Cough.

Risk GroupNumber of Clinic

Visits

Related Hospitaliz

ations Within 14

daysRate of Hospitalizations

within 14 Days

Elevated 650 39 6.0%Intermediate 711 9 1.2%Low 1709 2 0.1%

Unique people per risk group using the Broader definition of symptoms Fever ( by VS temp or complaint) + one of the other sx (ST, cough, uri, flu sx, bronchitis etc).

Pandemics are unpredictable Epidemiology reveals waves of

infection Ages/areas not initially infected

vulnerable in subsequent waves 1918- virus mutated into more virulent form

1957 schoolchildren first wave, elderly died in second wave

Public health interventions delay, but do not stop pandemic spread Quarantine, travel restriction show little

effect Temporary banning of public gatherings,

closing schools potentially effective in case of severe disease and high mortality

Delaying spread is desirable Fewer people ill at one time improve

capacity to cope with sharp increase in need for medical care

Lessons Learned formPast Pandemics

Is it ethical to not vaccine EMS /HCW’s against influenza?

Influenza is NUMBER ONE vaccine preventable disease.

Influenza is NUMBER ONE killer when compared to any other vaccine preventable disease.

Influenza is very contagious (from patients to workers then from workers to unsuspecting victims elsewhere).

Flu shots are cheap and safe

Seasonal flu causes up to 36,000-50,000 deaths per year in the United States. These are often vaccine

preventable.

Ethics of EMS /HCW’s influenza vaccination

Vaccination of EMS and health care workers (HCW) results in indirect protection of patients who are at high-risk for influenza.

Institutions caring for children and elderly have the responsibility to implement voluntary programs for vaccination against influenza.

When uptake falls short a mandatory program may be justified.

The caregivers have a duty not to harm one's patient when one knows there is a significant risk of harm and the intervention to reduce this chance has a favorable balance of benefit over burdens and risks.

Van Delden et al. The ethics of mandatory vaccination against influenza. Vaccine. 2008 Oct 16;26(44):5562-6. Epub 2008 Aug 21

Healthcare Professional Excuses That Result in Very Low Vaccination Rates Fear of adverse effects: 8–54% “Vaccination can cause influenza" 10–45% “Not at risk” 6–58% The times/locations of vaccination were

unsuitable for 6–59% (usually students and inpatient staff)

Doubt that influenza is a serious disease: 2–32%

Inefficacy of the vaccine: 3–32% (44% non-allopathic

providers) Fear of injections: 4–26%

Hoffman, C. Infection 2006; 34: 142–147

Novel H1N1 Vaccine Information

Vaccine should be available BY mid-October (195mln doses ordered). FDA approved today.

Studies on children and adults are under way. Seasonal influenza and H1N1 vaccines can be

given together (most current assumption). Two doses are likely to be necessary for

children, one dose for adults. Limited cost to the individual vaccinated. The H1N1 vaccine will reach the county through

the Grant County Health District and your hospital in parallel.

On-site vaccination of EMS recommended.

Novel H1N1 Vaccine InformationRecommended Target Groups (from CDC) Children and young people between the ages

of 6 months and 24 years of age, Pregnant women, Household contacts and caregivers of

children who are younger than 6 months of age,

Healthcare workers and emergency medical services personnel,

Adults 25-64 years of age with underlying risk conditions or medical conditions that increase their risk for complications from influenza.

Who should get the seasonal flu vaccine? Healthcare workers and EMS All children, age 6 months up to the 19th

birthday, especially those with illnesses like asthma, diabetes, or heart disease.

Anyone living with or caring for children especially babies under 6 months (who are too young to get flu vaccine).

Pregnant women. People age 50 and older. People with certain chronic medical conditions. People living in long-term care facilities. Others near those at high risk for flu

complications.

Intranasal influenza vaccine LAIV:“live attenuated influenza vaccine”

Intramuscular influenza vaccineTIV:“trivalent inactivated influenza vaccine”

Virginia Mason Flu Clinic Drive, 2006

http://www.preventinfluenza.com/summits/2007/Session_Four/Hagar_2007.pdf last accessed 08/01/2009

THIMEROSAL (C9H9HgNaO2S), or sodium ethylmercurithiosalicylate Because thimerosal is half mercury (47% Hg),

a vaccine with 0.01% concentration of thimerosal (in 0.5ml) = 0.005% concentration

of HgThat equals 25 micrograms of mercury per

0.5 mL of vaccine.

Most commercial fish contain an average of 23 micrograms of mercury per 8 ounces

of fish (i.e., 0.1 micrograms of mercury per gram of fish).