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2009 H1N1 PANDEMIC UPDATE FOR EMS
_________________________
Alexander L. Brzezny, MD, MPH
Grant 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 Illness
 Influenza-like
illness (ILI):
 Fever>100F (37.8C) AND
 Cough AND/OR Sore Throat
 Absence of other obvious
known cause
Influenza is a Respiratory Illness
 Influenza
(flu) is caused by a
virus that spreads easily by
coughing and sneezing.
Close contact within 6 feet.
 Can be transmitted by surfaces.

“Swine” Influenza virus
.08 -.12 microns
Staph aureus
1 micron
Residences
Social Density
Offices
Hospitals
8 feet
Elementary
Schools
12 feet
http://buildingsdatabook.eren.doe.gov/docs/7.4.4.xls
3-4 feet
16 feet
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
Human Virus
Avian Virus
Avian/Human
Reassorted Virus
Swine 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)
Whatcom
(1)
San Juan
Pend
Oreille
Okanogan
Skagit*
Ferry
Island
(1)
Stevens
Snohomish
(11)
Clallam
(1)
Chelan*
Jefferson*
Kitsap
(7)
Grays Mason
(3)
Harbor
(1)
Thurston
(5)
Pacific
Wahkiakum
Douglas*
King
(60)
Pierce
(22)
Lewis*
Kittitas*
Grant
(3)
Adams
Franklin
Yakima
(1)
Spokane*
Whitman*
Garfield
Columbia
Benton
(1)
Cowlitz* Skamania
Clark
(4)
Lincoln
Walla
Walla
Asotin*
Klickitat
*Reported non-hospitalized PanH1 influenza case(s)
Rate per 100,000:
0
0.1-1
2.1-3
3+
1.1-2
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, 2009
Total WA 2009 H1N1 Flu Hospitalizations
and Deaths
Posted September 11, 2009, 1:00 PM PT
Total WA Novel H1N1 Flu Hospitalizations
164
Total 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)
35
30
Number of cases
30
25
20
13
15
9
10
5
7
7
5
1
4
0
0
0
7
8
9
0
0
1
2
3
4
5
6
Length of stay (days)
*Incomplete reports on 43 cases
10+
Percentage of PanH1 cases
All 2009 H1N1 cases by age group &
hospitalization status
57.1
60
p<0.001
50
40
30
20
33.6
28.6
25.2
23.5
17.6
11.3
10
3.0
0
0-4
5-17
18-49
50+
Age group (years)
Hospitalized or fatal (n=119)
Non-hospitalized (n=532)
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
%
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
Lung diseases/conditions
*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
* Number of records where presence or absence of condition specified
78
Washington 2009 H1N1 Summary
39% of hospitalized/fatal cases reported
vomiting compared to 25% of nonhospitalized cases.
 74% of hospitalized cases had a pre-existing
condition compared to 22% of nonhospitalized 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.
Types of Protective Masks

Surgical masks


High-filtration respiratory mask (i.e. N95)


Easily available and commonly used for routine surgical and
examination procedures
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

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
Survival of Influenza Virus
Surfaces and Affect of Humidity & Temperature*

Hard non-porous surfaces 24-48 hours

Plastic, stainless steel



Cloth, paper & tissue



Recoverable for > 24 hours
Transferable to hands up to 24 hours
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)
Source: Bean B, et al. JID 1982;146:47-51
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.
H1N1 Influenza Virus Exposure
For use with exposure to patients/individuals with suspected or confirmed H1N1 Influenza only.
Assessment Flow Chart
Close Contact Exposure
(with no mask/PAPR* & within 6 feet of patient)
Limited Exposure
No
Directly exposed to patient's aerosolized
secretions by endotracheal intubation,
suctioning, ET tube management, oral suctioning,
or directly to patient's cough or sneeze.
- Wore mask during patient care
- Transported patient
- Cared for patient but did not have
close or prolonged contact
with patient's aerosolized
oral secretions
Yes
Less than 7 days
since exposure
No
No further follow-up
Yes
Complete Patient Information Profile
(page 2 of this policy) and
Complete Employee Incident Report &
see Emergency Department Physician
* Receive Prophylaxis
Self-monitor for "Influenza-like
Illness" symptoms for 7 days
after limited exposure
using "Symptom Diary" (page 3)
o
Temp is >100.4 F. and
you develop any of the first
4 symptoms of diary
No
Yes
- Notify Employee Health Service
- Fill out "Employee Incident Report"
- Stay home & report illness to \
Staffing Office or supervisor
* PAPR = purified air particulate respirator.
Note: The infectious period for H1N1 flu
is one day before symptom onset
until seven days after the patient's
onset of illness. If close contact occurred
with a case whose illness started more than 7 days
before contact, then prophylaxis is not necessary.
No further
follow-up
Effect of Prehospital and other
Community Interventions
1. Delay disease transmission and outbreak peak
2. Decompress peak burden on healthcare infrastructure
3. Diminish overall cases and health impacts
#1
Pandemic outbreak:
No intervention
#2
Daily
Cases
Pandemic outbreak:
With intervention
#3
Days since First Case
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 alcoholbased 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)
Unique people per risk group using the CDC definition of symptoms Fever ( by VS temp or complaint) + one Sore
Throat or Cough.
Risk Group
Related
Hospitalization
s Within 14
days
Number of
Clinic Visits
Rate of Hospitalizations
within 14 Days
Elevated
573
30
5.2%
Intermediate
645
8
1.2%
1540
2
0.1%
Low
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).
Number of Clinic
Visits
Related
Hospitaliza
tions
Within 14
days
Elevated
650
39
6.0%
Intermediate
711
9
1.2%
1709
2
0.1%
Risk Group
Low
Rate of Hospitalizations
within 14 Days
Lessons Learned form
Past Pandemics


Pandemics are unpredictable
Epidemiology reveals waves of
infection

Ages/areas not initially infected
vulnerable in subsequent waves 1918virus 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
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 2
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 Information
Recommended 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 vaccine
TIV:
“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 Hg
That 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).