PANDEMIC INFLUENZA A (H1N1) INFECTION PREVENTION & CONTROLJuly 2009 :PANDEMIC INFLUENZA A (H1N1) INFECTION PREVENTION & CONTROLJuly 2009


Overview :Overview Background to Influenza Pandemics Pandemic Influenza A (H1N1) (background) Symptoms Incubation period Infectivity Diagnosis Treatment Vaccination Infection Prevention & Control advice for management of influenza Summary


epidemiological terms :epidemiological terms Endemic- self sustaining infections or diseases that are always present. Epidemic- outbreak of an infectious disease in a defined population during a specific period of time. Pandemic- an epidemic spreading over a wide area e.g. National, regional, global epidemics.


Influenza A :Influenza A Originates in birds. Categorised into subtypes on the basis of 2 surface antigens: hemagglutinin (H) and neuraminidase (N) H- 16 subtypes N- 9 subtypes In humans H1, H2, H3, N1 and N2 are the common subtypes seen to date.


The “usual” evolutionary path for most human flu strains :The “usual” evolutionary path for most human flu strains Birds usually acquire the influenza virus first. The virus then will typically mutate to swine herds. Ultimately the virus may then mutate into a form transmissible between humans.


3 Conditions Needed For A Flu Pandemic :3 Conditions Needed For A Flu Pandemic A new virus subtype must emerge to which there is little or no immunity. It must infect humans & cause illness. It must spread easily & sustainably among humans.


Pandemics and Pandemic Threats of the 20th Century :Pandemics and Pandemic Threats of the 20th Century 1918-19 “Spanish flu”. H1N1 1957 “Asian flu”. H2N2 1968 “Hong Kong flu”. H3N2 1976 “Swine flu” episode. H1N1 1977 “Russian flu”. H1N1 1997 “Bird flu” in HK. H5N1 1999 “Bird flu” in HK. H9N2 2003 “Bird flu” in Netherlands. H7N7 2004 “Bird flu” in SE Asia. H5N1 2009 “Swine flu” in Mexico. H1N1


Slide 11:It seems likely that the new version of H1N1 resulted from a mixing of different versions of the virus, which may usually affect different species, in the same animal host. Pigs provide an excellent 'melting pot' for these viruses to mix and match with each other.


Slide 12:Although called swine flu due to it predominantly containing swine strains, the World Organisation for Animal Health have proposed the name New Influenza A (H1N1)


Influenza viruses do not affect the safety of pork..... :Influenza viruses do not affect the safety of pork..... World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO) advise that as with any raw meat, pork should always be properly handled and cooked to eliminate a range of food safety concerns.


Slide 14:Where is H1N1 found?


Infection rates (29th July 2009) :37 cases per 100,000 population in the week ending 26th July 2009. Peak reported Influenza like illness rate during last winter was approximately 120 per 100,000. Infection rates (29th July 2009)


HSE H1N1 figures :HSE H1N1 figures 0- 4yrs: 10% 5-19yrs: 30% 20-44yrs: 43% 45-54yrs : 14% Over 65yrs: 3%


Incubation Period :Incubation Period According to the Health Protection Agency, the incubation period for swine flu (time between infection and appearance of symptoms) can be up to seven days, but is most likely to be between two and five days.


Period of infectivity :Period of infectivity Persons are infectious from 24 hours per onset of symptoms and during the most symptomatic period, usually three to five days from clinical onset in adults . Peak shedding of the virus occurs during the first 24- 72 hours of illness. Shedding does not usually continue once the clinical illness has resolved


16th July Policy change in public health management of influenza A (H1N1) :16th July Policy change in public health management of influenza A (H1N1) Focus shifted from containment to mitigation Focus moved to treating and preparing for mass immunisation with vaccine.


New approach (16th July) :New approach (16th July) Stopping routine contact tracing. Test & Treat: Patients who appear to have severe symptoms Patients in high risk groups Only offering antivirals to very high risk contacts


High risk groups (HPSC 16/7/09) :High risk groups (HPSC 16/7/09) Chronic lung heart, kidney, liver or neurological disease People who are immunosuppressed Diabetics People over 65 Children under 5 People on medication for asthma Severely obese people Pregnant women


Very high risk groups :Very high risk groups Contacts of cases who require treatment even though they do not have the illness: Pregnant women Those on treatment foe asthma Those who are very obese


diagnosis :diagnosis To diagnose swine influenza A infection, a respiratory specimen is collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding virus).


Treatment :Treatment Two anti-viral drugs, either of which is recommended for use in people with human swine influenza infection - Tamiflu and zanamivir. These medicines work best if started soon after getting sick (within 2 days of symptoms).


What do antivirals do :What do antivirals do Antivirals are not a cure, but they help you to recover by: relieving some of the symptoms, reducing the length of time you are ill by around one day, and reducing the potential for serious complications, such as pneumonia.


Slide 27:Zanamivir (Relenza): 10 mg (2 inhalations) once daily for adults & children = 5 yrs old. Oseltamivir (Tamiflu): orally adults and children = 13 years old - 75 mg once/d (HSE stockpile for 47% of population)


Can I take antiviral drugs if I am pregnant? :Can I take antiviral drugs if I am pregnant? An expert group reviewed the risk of antiviral treatment in pregnancy, which is extremely small - much smaller than the risk posed by the symptoms of swine flu. Women who are breastfeeding should continue to do so while receiving antiviral treatment, as this is not contraindicated. If a mother is ill, she should continue breastfeeding and increase feeding frequency


Vaccination :Vaccination No vaccine available to protect humans from Pandemic influenza (H1N1) Vaccine should be available by September/ October. Two doses of the vaccine may be necessary DoHC has advance agreements for 7.7 million doses of the pandemic vaccine.


Treatment :Treatment If you get sick contact your GP by phone. They will decide if you need testing or treatment. 98- 99% of cases to date have been mild and have not required admission to hospital. Most people who get flu recover at home without antiviral medication. Only people with severe symptoms or high risk groups need to be prescribed antiviral medicine.


Staff :Staff Staff with symptoms of pandemic influenza should be excluded from work to avoid infecting patients, colleagues and others. Staff assigned to care for patients with pandemic influenza will not be assigned to care for non-influenza patients or work in non-influenza areas. Staff caring for non-influenza patients can be redeployed to an area segregated for the care of influenza patients.


Patient Placement :Patient Placement Place the patient in a single room or cohort with other patients with confirmed or suspected influenza. To control entry, signage will be displayed warning of the segregated pandemic area. Avoid gathering patients in communal areas. If patient movement is essential, minimise the risk of infection to others by placing a mask on the infected patient


Visiting during an outbreak :Visiting during an outbreak Visiting may be curtailed for duration of Pandemic outbreak. Visitors must adhere to infection control advice, infection control advice will be displayed on posters throughout the hospital.


The sick person should ALWAYS wear a facemask when out of their room :The sick staff member should Stay at home for the duration of their illness. Stay in a separate room and keep door closed Limit time spent in common areas Use a separate bathroom if possible Dispose of used tissues in the nearest waste bin Wash hands often with soap and water, and especially after coughing and sneezing. Alcohol-based hand cleaners are also effective. The sick person should ALWAYS wear a facemask when out of their room


Care givers should ALWAYS wear a facemask when in the sick persons room :Care givers should ALWAYS wear a facemask when in the sick persons room Caregivers should if possible: Be limited to one person People with certain medical conditions should avoid being carers. Spend the least amount of time possible in close contact with patient Clean bathroom used by sick person, daily if possible, with household disinfectant e.g. bleach Wear a facemask when entering the sick persons room


Slide 36:Droplet Contact


Infection Prevention & Controlfor Routine Care :Infection Prevention & Controlfor Routine Care Hygiene/ cough etiquette. Hand hygiene. PPE- Whenever risk of infectious H1N1 aerosols exists (within 1 meter of infected person who’s coughing & sneezing), use surgical mask, eye protection, aprons, gloves. Waste & Laundry Management Isolation/ cohorting symptomatic patients Environmental hygiene. Care of Patient equipment


Hand Hygiene :Hand Hygiene Strict adherence to the hospitals Hand Hygiene Policy is essential. Patients hands will be heavily contaminated, because of frequent contact with their nose, mouth and tissues that they have used in respiratory hygiene. Their hands will also make frequent contact with their immediate environment. Scrupulous hand hygiene among staff before and after contact with patients or their close environment is vital to protect themselves and other patients. Good hand hygiene among patients is also required.


Hand Hygiene Education :Hand Hygiene Education Why to wash hands When to wash hands How to wash hands Technique Products Facilities


Hand hygiene Preparation :Hand hygiene Preparation It is important to note that nails should be kept short and nail varnish, false nails and hand or wrist jewellery should never be worn when working in the clinical area. The wedding band is allowed providing that it is a plain band with no stones, but always remember to move it when performing hand hygiene to clean the skin underneath.


Cough & sneeze etiquette :Cough & sneeze etiquette Cover nose and mouth with disposable single use tissues when sneezing, coughing, wiping and blowing nose. Dispose of tissues promptly in nearest yellow bag. Ensure patients have an adequate supply of tissues. Wash hands after coughing sneezing, using tissues or contact with respiratory secretions and contaminated objects. Keep hands away from the mucous membranes of the eyes and mouth.


Cough & sneeze etiquette :Cough & sneeze etiquette Catch it Bin it Kill it


Personal Protective Equipment :Personal Protective Equipment Put on PPE Before entering room Removing PPE Remove gloves and aprons/gowns in room Decontaminate hands Remove mask/respirator in ante room or outside room with door closed


Removing gloves :Removing gloves Grasp glove cuff with opposite gloved hand & peel off inside out. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist & peel off. Discard gloves into waste container.


Removing apron. :Removing apron. Unfasten ties Peel gown away from neck and shoulder Turn contaminated outside toward the inside Fold or roll into a bundle Discard in waste container


Removing Masks :Removing Masks Avoid contact with contaminated front part of mask/respirator Starting at back of head, grasp bottom tie/elastic band, then top tie/elastic band & remove Discard masks in waste container


facemasks :facemasks A surgical facemask should be worn for patient care within 1 meter/ 3 feet of a patient suspected or confirmed to have influenza. Surgical masks should be changed when moving between areas where flu and non flu patients are cared for, hourly, or whenever they become moist. Masks are of little use if worn for more than 1 hour.


facemasks :Masks should cover both the nose and mouth and not be allowed to dangle around the neck after usage. Masks should be handled as little as possible. Masks must be worn once and discarded as healthcare risk waste. Never re-use once removed. Hand hygiene must be performed after disposal is complete. facemasks


Aerosol Generating Procedures :Intubation CPR Respiratory airway suctioning including tracheostomy suctioning) Nasopharyngeal aspiration Autopsy procedures Nebulisation CPAP/BiPAP High frequency oscillating ventilation Aerosol Generating Procedures


For Aerosol Generating Procedures :For Aerosol Generating Procedures Adhere to strict hand hygiene FFP2 or FFP3 mask (correctly fitted) Long sleeved disposable gown Gloves Eye protection/goggles (risk of splashing)


Nebulisers :Nebulisers As nebulisation is an aerosolising procedure, the use of nebuliser therapy should be minimised wherever feasible without compromising patient care. To avoid unnecessary exposures, only staff needed to perform the procedure should be present.


Studies have shown that the influenza virus survives for : :Studies have shown that the influenza virus survives for : 24- 48 hours on hard, non porous surfaces 8 to 12 hours on cloth, paper and tissue 5 minutes on hands.


Hospital Environmental Hygiene :Hospital Environmental Hygiene During the influenza outbreak remove all fans from clinical areas. Thoroughly clean and disinfect the environment and all patient care equipment using actichlor plus 1000ppm (1 tablet per litre of water), paying particular attention to frequently touched sites and equipment close to the patient. Soft furnishings will be difficult to clean and may need to be removed and stored during widespread hospital outbreak. Don’t refill water bottles canteen.


Office Areas :Office Areas Researchers found that the following four surfaces harbor the most bacteria: Phones Desks Computer keyboard Computer mouse


Slide 58:When possible Dedicate medical devices to single patient use. Use disposable materials. Always Follow manufacturer’s instructions for cleaning and disinfecting reusable medical equipment after use. Only take essential equipment and supplies into the room. Do not stockpile as unused stock will have to be discarded on cessation of additional precautions. Never Take patient charts/records into the room. Patient Equipment


The Influenza A(H1N1) virus can persist on non-porous surfaces for 24 hours or more :The Influenza A(H1N1) virus can persist on non-porous surfaces for 24 hours or more Pay special attention to frequently touched sites and equipment close to the patient On Discharge Prior to initiating environmental cleaning and disinfection all privacy, shower and window curtains must be removed and sent for laundering. All disposable items must be discarded


Stop the spread of infection by: :Stop the spread of infection by: Avoid close contact with people who appear unwell and have fever & cough. Always carry tissues Always cover nose & mouth with clean tissues when coughing or sneezing. Always dispose of used tissues into a bin immediately. Wash hands thoroughly with soap & water or alcohol gel regularly. Clean surfaces regularly to kill germs Don’t be complacent, as it is too soon to assume it will be a mild infection.


Slide 61:Thank you. Any Questions?