Transcript Infection Prevention & Control

1
Update re Pandemic Influenza
and Precautions
D. Moralejo PhD, RN; Marion Yetman MN, RN, CIC;
Paula March BN, RN et al.
Fall, 2009
Infection Prevention & Control
Occupational Health Hygiene
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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…
•
•
•
•
H1N1
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 #1
4Y
La Gloria
Mexico
• April 26: 6 cases in Canada: 4 NS and 2 BC
• June 11: WHO increases the pandemic alert
level to phase 6
• June 11: First lab confirmed cases in NL
• Aug 1: > 10,000 cases in Canada
• Aug 22: 1441 hospitalizations, 71 deaths
Pandemic
(H1N1) 2009
Increased
and sustained transmission
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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 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 > Defences
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Breaking the Chain
of Infection: IP&C
Break any
link!
• 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
Applicable for all infections!
– Vaccinate
– Improve defences e.g., stop
smoking, nutrition, control
diabetes
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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
From
the
School
of Photographic
From the
School
of Photographic
Arts and Arts and Sciences, Rochester Institute of Technology
Sciences, Rochester Institute of Technology
Transmission
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!
The Chain of Infection!
One person
can spread
the virus to
multiple
others
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Influenza: Breaking the Chain
Agent
Influenza virus
Transmission
– Droplet (cough/sneeze)
+
– Contact with
environment/objects
contaminated with respiratory
secretions +
Susceptible host
– No antibody
– Reduced WBC or normal
defences
Eliminate Agent
– Clean environment
– Antiviral drugs
Transmission
– Droplet: Mask and
Eye Protection
– Contact
• Hand Hygiene
• Gloves, [Gown]
• Distance
Susceptible host
– Vaccinate
– Strengthen defences
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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
What is the need for hand hygiene?
Is ABHR/a sink available?
Is there potential for exposure to
secretions via coughing or sneezing
or to other blood/body fluids,
mucous membranes, non-intact
skin or contaminated objects?
What PPE do I need?
What other risks for transmission
are there?
What other actions
are required?
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RP Helpful for Influenza
 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
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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)
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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
√
√
√
√
√
√
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
Similar*
S&S
Similar
Transmission
Droplet/Contact Droplet/Contact
Incubation
2 days
Period of
5 days
communicability
Where spread 1° Community
7 days
7 days
1° Community
* But younger people affected, also certain populations: aboriginal, obese
persons & pregnant women--ARDS in severely ill
Seasonal and Pandemic:
Differences
Seasonal Influenza
Pandemic Influenza
• Some immunity from prior
exposure to similar viruses
• Novel virus – NO immunity
• Happens every year
• Two or three times a century
• Two waves
• Usually from Jan – April &
stops
• 10-25% of pop affected
• Very young and old
• Vaccine available pre-season
which offers protection
• Anti-virals available
– Except >60 years
– 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
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Preventing influenza: 1918 versus
2009 public health messages
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Shared Responsibility
Organizational
• 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
HCW: Direct Care
• Point of care risk
assessment/ screening
• Hand hygiene
• Droplet/Contact
Precautions
• Teach/facilitate cough
etiquette
HCW: Other
• Self screening
• Vaccination
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Simplifying the Messages
• Clean
• Cover
• Contain
• Charge up
your
defences
–Choose
to be
vaccinated!
Clean
Cover
Contain
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1. Contain
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 hygiene
Screening 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
ILI Screening
New or
worsening
cough or
SOB?
No
Fever or
chills in
past 24
hrs?
No
RP
Yes
Yes
1 of:
Fever or
chills in
past 24
hrs?
No
Headache,
sore throat
joint or
muscle
pain, severe
fatigue?
Yes
Initiate Droplet and
Contact Precautions
and continue assessment
Maintain until diagnosis
confirmed or ruled out
Yes
No
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More about “Contain”
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
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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 receptacles
• Nose/mouth and eyes of HCWs
Droplet
Precautions!
– 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
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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!
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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!
Choose to be
Vaccinated!
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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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Seasonal Influenza Vaccine
• 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
• 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
Only 1060% of
HCWs get
vaccinated
LTC >
Acute
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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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Myths About the Flu Vaccine
I never get sick so don’t need it
20% have few S&S but still
pass the virus to others
Flu vaccine causes the flu
Contains dead virus –
cannot cause flu
The flu shot doesn’t work
70-90% effective when
good match
I’m pregnant and shouldn’t get the
+
vaccine
Flu vaccine is safe during
pregnancy and is
recommended
Getting the vaccine weakens your
immune system
Vaccine prepares and
boosts your immune system
against the virus
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!
More education
Easier access
Make mandatory?
Declination forms?
• Vaccinate self
• Encourage others
and facilitate access
• At minimum, do not
discourage others!
What else
do we need
to do to get
HCWs
vaccinated?
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Putting It All Together
• Contain
– Screen
– Distance
• Cover
–
–
–
–
Cough
Nose/mouth
Hands
Clothes
• Clean
– Hands
– Environment
• Choose to be
vaccinated
Charge up defences
Routine Practices
• For all patients!
Additional Precautions
• Droplet and Contact for ILI
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
Don’t self-contaminate when
removing PPE!
• Risk assessment tools available to help
identify risk given patient condition and
interaction and PPE to use
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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
Over use
can lead to
resistance!
• 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
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What to Teach Others
Check yourself for ILI S&S
Prevent flu in yourself!
Clean & Choose
Clean,
Cover, Contain,
Choose to be
vaccinated
Prevent flu in others!
Cover & Contain
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Take Home Messages
• Contain
– Screen
– Distance
• Cover
–
–
–
–
Cough
Nose/mouth
Hands
Clothes
• Clean
– Hands
– Environment
• Charge up defences
– Vaccinate
Routine Practices
• For all patients!
Additional Precautions
• Droplet and Contact for ILI
For now, same precautions for
seasonal and pandemic strains
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Credits
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 Committee
 Eastern Health: Donna Ronayne & Ada Fowler
 Central Health: Penny Ralph & Shelley Woolfrey
 Western Health: Paula Price & Jackie Young
 Labrador-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
Infection Prevention & Control
Occupational Health Hygiene
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Thank you! Any Questions?