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Pandemic Influenza Presentation for Vancouver Island Health Authority Employees

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    Welcome Introduction Sign-up sheet. Send to darren.buckler@viha.ca or patricia.bleackley@viha.ca Reminder re Mute button for those on Video-Conference Purpose of Education Sessions: To ensure everyone at VIHA understands VIHA Pandemic Readiness To ensure VIHA staff have received Education via Video Conferencing or Reviewing on-line Education or attended Facility session with Clinical Educators or IPCPs.

    Never say Never!

    D - Dec – March according to Health Canada

    B - Anytime Pandemic influenza is dictated by the original source, and therefore geographical and cultural influences impact on the start time of an outbreak. The development of the virus will impact the time line and waves of the outbreak

    C. When touching something wet and it isn’t yours – according to routine practices D. When caring for a patient with influenza – according to droplet precautions

    Within 2 meters (6 feet) of a coughing febrile patient wear a 120 mmHg procedure mask with attached face visor, according to routine and droplet precautions AND D. Within 2 meters (6 feet) of a patient on precautions for ILI or influenza wear a 120 mmHg procedure mask with attached face visor according to droplet precau tions

    Influenza Pandemics occur when a novel strain of virus causes a world-wide epidemic affecting an exceptionally high proportion of the population at the same time. This is different than the annual seasonal epidemics which happen on a regular basis, in different hemispheres, at different times of the year. Influenza Pandemics have been known since the 16th Century at intervals of 11 - 42 years. Russian pandemic 1889 - 1890 (H2N2) Spanish pandemic started in March 1918 to June 1920 (20 – 40 m deaths) Asian pandemic ended in1958 Hong Kong pandemic ended in 1969 On March 18 th , 2009 surveillance began picking up cases of influenza-like illness in Mexico and numbers steadily rose. A number of these cases were confirmed as a new strain of Influenza A labeled as swine flu (H1N1). The symptoms for this influenza for most cases have been the usual symptoms of influenza.  On the 26 th of April further spread was reported by the World Health Organization, with 20 cases identified in the US. These were the early reports that alerted us that pandemic was possible.

    By June 11 th widespread human infection led to the World Health Organization announcing Pandemic Alert Level Phase 6 Canada August 30 th update: 7107 cases 1441 hospitalized 278 ICU 72 deaths BC: 42 severe cases 18 ICU 4 deaths

    Table showing the Differences between Annual Seasonal Epidemics and Pandemics. The reason for annual influenza immunization is because of the small continuous changes that happen causing Antigenic DRIFT which results in a loss of immunity or vaccine mismatch from year to year. Antigenic SHIFT occurs only in influenza virus A because this virus infects more than just humans. It is the process by which at least two different strains of a virus combine to form a new subtype. Antigenic SHIFT is associated with pandemics because people do not have immunity to the new strain. Pandemic Influenza comes in waves. The reasons for multiple waves of varying impact is not precisely understood however, it probably includes adaptation of the virus to its new host, demographic or geographic variation, seasonality, and the overall immunity of the population. The occurrence of multiple waves provides time for health authorities to implement control strategies for successive waves. Based on the last two pandemics assumptions were made: it was estimated that the next pandemic virus would arrive in Canada within 3 months after it emerged in another part of the world. The first peak of illness in Canada would occur within two to four months after the virus arrived in Canada. The first peak in mortality would occur one month after the peak in illness. A second wave occurs within 3 to 9 months of the initial outbreak wave and may cause more serious illnesses and deaths than the first. Each wave of illness will last 6 to 8 weeks. When pandemic virus arrives close to the usual annual influenza season, the time interval between emergence, arrival and/or peak illness and mortality is shortened. As a result of the virus adaptation and spread, waves 2 and 3 will be worse than the first wave. This speculation is based on studying previous pandemics. The following BC worst case scenario assumptions are based on studies from previous pandemics: As many as 3 million BC will be infected As many as 1.8 million will become clinically ill Over 600,000 will make a visit to a H CW Over 20, 000 will require hospitalization Approx 7, 000 deaths Having said seasonal influenza is predictable.....two notable influenza outbreaks occurred in Yukon during the summers of ‘96 and ’97.....which resulted in an international collaboration between Alaska, Yukon, and BC. You can review those outbreaks in the MMWR. Knowing our seasonal influenza season is December - March you need to keep in mind that the Southern Hemisphere is experiencing their seasonal influenza in our off-season and so influenza came up the coast via our summer cruise ship season. Vaccine will be the primary means of pandemic influenza prevention. The supply is non-existent and then limited during the early stages of the pandemic. Plans during a first wave identify lack of influenza vaccine and need to establish a list to prioritize who will receive vaccine when it becomes available. for vaccination. Seasonal Influenza affects young (65 (Nursing Home Residents), Pregnant Women, and Adults with underlying health problems are at serious risk for serious complications. Children <18 yrs. are at risk for Reye’s Syndrome which is a potentially fatal disease that affects the brains and livers of kids receiving aspirin therapy who then acquire a viral illness. Pandemic Influenza affects healthy people 15 - 40 years with no underlying health problems and pregnant women in the third trimester. Seasonal influenza = schools normally remain open workers stay home when ill Pandemic influenza = school & business closures due to increased abseentism and orders from CMOHs. Business closures could include daycares (i.e. kids and adults), restrictions of public gatherings, travel restrictions. These impacts will affect domestic and world economies. Do you have a home plan if closures occur? Antivirals were distributed from the national stockpile a few years ago to designated depots across Canada based on population per capita. Antivirals Zanamivir (Relenza) and oseltamivir (Tamiflu) are effective antivirals for H1N1. Antivirals are used to reduce complications, reduce the symptoms, or shorten the length of illness. They should be taken 48 hours within getting sick to be most effective. Antivirals work by reducing the viruses ability to reproduce, however they do not provide immunity against the virus. Antivirals should only be taken by people who are ill unless advised by medical staff such as their family doctor. Seasonal influenza vaccine is prepared based on known strains & is available for annual flu season. Vaccine is the primary means of prevention along with hand-hygiene and respiratory etiquette (i.e. coughing into the crook of your arm or into a tissue; sneezing into a tissue; disposing of tissues in the garbage and washing your hands or using alcohol-based hand rub). Vaccine is designed to produce immunity by stimulating the production of antibodies. The federal government has purchased 50.4 million doses of H1N1 vaccine . Vaccine development can take up to 6 months. Decisions regarding vaccine priority groups is in the final stages. Seasonal or Pandemic severity of disease varies among the population, from very severe (requiring hospitalization) to subclinical illness, where the person may not realize they have acquired it, but their immune system will react in order to produce antibodies to the virus, should they come into contact with it in the future.

    Influenza is a respiratory illness caused by influenza virus A, B or C A and B are the most common cause of seasonal influenza epidemics. Influenza A crosses species and is found in many birds and mammals Influenza B is exclusive to humans Influenza C usually infects children causing mild disease with life-long immunity Influenza A is sub-typed to figure out the combination of virus surface proteins (i.e. H emagglutinin and N euraminidase) that’s causing the particular influenza.

    Background information about names of flu virus strains: Influenza A virus strains are categorized according to two proteins found on the surface of the virus: hemagglutinin (H) and neuraminidase (N). In the naming convention of viruses, the protein classifications become part of the name as in H1N1; H for the Hemagglutinin and N for the Neuraminidase. Hemagglutinin binds the virus to the cell it is infecting. Neuraminidase is an enzyme that lets the virus be released from the host carrier cell. Influenza A virus strains are assigned an H number and an N number based on which forms of these two proteins the strain contains. There are 16 H and 9 N subtypes known in birds, but only H 1, 2 and 3, and N 1 and 2 are commonly found in humans. H1N1 evolved from a virus that started as a flu that only pigs could get, which is called H1N1, too. This mutated to a strain that could also infrequently infect humans who were in very close contact with pigs, such as farmers who raised them. The new "Novel H1N1" virus was a further mutation that combined human, bird, and swine flu genes.

    Antigenic shift is the process by which at least two different strains of virus combine to form a new type. It only occurs in Influenza Type A. In the case of influenza, different influenza A viruses from different animal species (including human) mix and create a new influenza A virus. For example, if a pig were infected with a human influenza A virus and an avian influenza A virus at the same time, the new viruses could mix genetic information and produce a new virus that still has a high genetic makeup from the human virus. The resulting new virus may then infect humans and spread from person to person. Because the human population has little or no immunity to this new Influenza A virus, it can be easily transmitted and a high number of people will acquire the virus, resulting in a pandemic.

    Complicated but you get the picture.

    Hopefully this picture makes this a bit easier to understand.

    Influenza causes respiratory illness that is easily transmitted in crowded and enclosed spaces. People often say the illness came on so fast it feels like I was hit with a MACK truck.

    Differential Diagnosis is important because people seeking care may or may not have influenza. If it is an ILI presentation it could be seasonal or pandemic influenza.....you can’t tell by its presentation.

    Children….and rarely adults……may present with: Nausea Vomiting Diarrhea

    Viral shedding is 24 hours before to 7 days after for H1N1 Peak shedding correlates with patient’s temperature Viral shedding timelines: Healthy adults: 3-4 days Hospitalized immunocompromised adults: 4-5 days Elderly adults: up to 7 days Outpatient children: 7 days Nosocomially infected infants: up to 21 days Severely immunocompromised (advanced HIV, BMT, leukemia): median 7 days - 63 days

    The influenza virus is transmitted in large droplets of respiratory secretions. We know that even with a forceful cough, the distance these droplets can travel before dropping to the floor or other horizontal surfaces is between 3 – 6 feet (1 – 2 metres). The 120 mm Hg procedure/surgical masks provided are a barrier to this type and size of droplet. The only time an N95 masks has to be worn is when aerosol generating medical procedures (AGMP) are being done and the patient has ILI or influenza or contact to ILI because these procedures reduce the size of these droplets, allowing the virus to suspend on much smaller droplets or aerosols. Because the droplets fall onto horizontal surfaces & equipment, contact transmission is also a risk which highlights the importance of hand hygiene and housekeeping.

    Annual Seasonal Epidemics High Risk Groups: Children < 5 yr Adults > 65 yr (nursing home residents) Pregnant women (first trimester – fever causes problems for the developing fetus) Adults with chronic illness Children < 18 yr receiving long term aspirin therapy as this predisposes them to Reye’s Syndrome which affects the brain and liver and is often fatal.

    Vaccines designed to produce immunity by stimulating the production of antibodies. The federal government purchased 50.4 million doses of H1N1 vaccine. Vaccine development takes up to 6 months. Decisions on vaccine priority groups is being determined. Those who will benefit most from immunization and those who care for them include: People under 65 with chronic health conditions Pregnant women Children 6 months to less than 5 years of age People living in remote and isolated settings or communities Health care workers involved in pandemic response or the delivery of essential health care services Household contacts and care providers of persons at high risk who cannot be immunized or may not respond to vaccines Populations otherwise identified as high risk Others who would benefit from immunization include: Children 5 to 18 years of age First responders Poultry and swine workers Adults 19 to 64 years of age Adults 65 and older Antivirals are used when patient is at great risk for complications NOT for mild illness within the first 48 hours of getting sick to be most effective. Zanamivir (Relenza) and oseltamivir (Tamiflu) are effective antivirals for H1N1. Antivirals are used to reduce complications, reduce the symptoms, or shorten the length of illness. Antivirals work by reducing the viruses ability to reproduce, however they don’t provide immunity against the virus. Antivirals should only be taken by people who are ill unless advised otherwise by medical staff such as their family doctor.

    Stay home if you’re sick…..as well as STAR scheduling and your Manager, W&S also needs notification Use a tissue for sneezes. Use tissue or the crook of your arm for coughs Put used tissue in the garbage – not your pocket If hands are soiled with respiratory secretions....use soap and water....if not, use ABHR Keep hands away from your face to keep the influenza virus from entering your body through your mucous membranes

    During the early stages of an Influenza Pandemic hand hygiene is the only preventative measure available during a pandemic

    Additional Precautions are required when routine practices are not sufficient to prevent transmission, and the type used is determined by how the organism is spread. In addition to routine practices, droplet precautions and Contact Precautions are required to prevent transmission of influenza. Droplet precautions prevent transmission spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet route means spread by large particle droplets when patients cough sneeze, or talk loudly/forcefully. Special air handling and ventilation are NOT required to prevent droplet transmission. Droplet Precautions include the use of 120 mmHg Procedure Surgical Mask with attached visor. Contact Precautions include Personal Protective Equipment (i.e. impermeable gown & gloves for direct care). AGMP treatments and diagnostic procedures the use of airborne precautions.

    Please remember that patients admitted with these diagnosis who have influenza symptoms or recent exposure to influenza must be placed on Droplet Precautions until influenza or some other contagious Respiratory infection has been ruled out. All Patients with SEVERE RESPIRATORY INFECTIONS or suspected ILI must be reported to Infection Prevention and Control as soon as possible, in order for Public Health to be notified in ‘real time’ to facilitate community follow-up and contact tracing.

    Self explanatory!

    These are the Four Key Moments of Hand-Hygiene Always Use Soap & Water when your hands are physically soiled following contact with organic matter such as blood/body fluids, including respiratory secretions and feces & after contact with items known to be contaminated (bedpans, urinals, wound dressings, etc. Soap & Water & ABHR easily inactivates the influenza virus.

    Additional Precautions are for staff having direct patient care – this is not for when you pass someone in the hallway. H1N1 influenza is like any type of influenza and droplet precautions must be put in place. Staff providing care within 2 metres of a patient with ILI must wear a 120 mm Hg procedure/surgical mask with attached face visor for eye protection. The use of gloves and a gown provides protection from contact and contamination from respiratory secretions. Hand hygiene always follow contact with a patient, even when gloves are worn.

    Patients with a forceful cough should always be encouraged to wear a mask, however some patients will be too sick to do this, or unable to comply with this for a number of reasons. Staff are still required to wear a 120 mm Hg surgical procedural mask with attached face visor for eye protection. Remember, it is the large droplets that hold the influenza virus when a patient is coughing. This is different when a patient is undergoing a AGMP.

    These are potential time frames for indirect contact transmission.

    AGMPs are any procedures carried out on a patient that can induce the production of aerosols of various sizes, including droplet nuclei. These procedures will be performed as necessary for the patients needs and treatment. For patients undergoing an AGMP who have ILI or influenza or are at risk for H1N1 because of contact, staff must wear an N95 mask with full face visor. Staff who are likely to be involved in these procedures will have been fit tested, and must wear the mask for which they were fit-tested. CPR is not listed here, however it is recognized that suctioning and non-invasive positive pressure ventilation form part of CPR. When performing suctioning on intubated patients, a closed suctioning system should be used when possible. If HCW breathing becomes difficult or the respirator becomes damaged or contaminated by body fluids, the wearer should go to a safe area and change the N95 respirator immediately. There are no indications for the use of personal air-purifying respirators (PAPRs) in the care of H1N1.

    The first line of respiratory defense is the 120 mm Hg standard procedure surgical mask available with attached face visor. This is a safe barrier from all large droplet transmitted micro-organisms like influenza. There are tasks and certain infections which mean much smaller droplets or aerosols are a risk in transmission. Tasks include aerosol generating medical procedures (AGMP), such as suctioning, bronchoscopy and chest physio to get an induced sputum specimen. For these types of tasks when there is a risk of H1N1 influenza, staff who are involved in the procedure must wear a fit tested N95 mask. This means that only staff who have been fit tested can be involved, and must wear the mask they were told to wear at their fit testing. VIHA only uss respirators that are NIOSH (the National Institute for Occupational Safety and Health) approved. These masks are comprised of tiny fibres that are electrosatically charged, ensuring adequate filtration.

    Annual fit testing is a WorkSafe BC requirement. Changes in your weight, dentures, among other things can affect the shape of your face and you may not be able to wear the same type of mask. An N95 provides the highest level of protection against airborne infectious agents because of the seal. This may seem a bit obvious but - you breath through the N95 mask which filters the airborne particles not allowing them to enter your lungs. N95 Masks are not appropriate for chemical spills.

    To ensure that an adequate and safe seal is achieved, all staff who are required to wear an N95 mask must be fit tested annually, and wear the mask for which they were fit-tested. There are 2 different suppliers of N95 masks to VIHA, 3M and Kimberly Clarke with a total of 5 different masks in our supply which allow us to successfully fit test staff in at least one of the five choices. Point out the different brands/styles on the photos for clarification (photo 1 = 3M 1870 one size only, photo 2 = 3M 1860 Small or Regular, and photo 3 – KC aka Duckbill Small or Regular).

    As already said, the first line for staff providing care to patients with influenza, including H1N1 is the procedural or surgical mask. The masks we advise for staff to wear come with an attached face/eye shield to protect from droplets entering the eye. If these are not available, and you have to wear a procedure surgical mask without an attached face shield, a separate face shield or goggles must also be worn.

    Masks must be removed last to protect the wearer while they are removing other personal protective clothing. They must also only be removed by the ties/elastic to reduce the risk of contaminating the hands and then the face. Never remove a mask by grasping the front. Remember to do hand hygiene before and after mask removal. If not removed N95 masks are safe to be worn for up to 8 hours. Procedural/surgical masks should be changed more frequently, so staff should be vigilant about how damp/wet a mask of any type is becoming and change at that point.

    Perform hand-hygiene before donning PPE and before putting mask on. GOWN: Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in back of neck and waist MASK or RESPIRATOR: 120 mm Hg Surgical Procedure Mask with attached face visor. Secure loops or ties at middle of head & neck. Fit snug to face and below chin. For AGMP use N95 with full face shield. Use the correct N95 for which you were fit-tested. GLOVES: Extend to cover wrist of isolation gown. REMEMBER TO USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION Keep hands away from face Limit surfaces touched Change gloves when torn or heavily contaminated Perform hand hygiene

    To protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions Remove soiled gown promptly, and wash hands immediately PS Never wear your stethoscope around your neck

    Remember to do hand-hygiene before putting a mask on and after mask removal.

    One more time……Hand hygiene before and after!

    Wash hands before putting gloves on and immediately following removal Don gloves just before patient contact or task requiring gloves Wear gloves when touching blood & body fluids (i.e. secretions, excretions, mucous membranes and non-intact skin) or contaminated items Work from clean to dirty Don’t touch face or adjust PPE with contaminated gloves Only touch environmental surfaces as necessary during patient care

    Remove PPE at doorway or in an anteroom except for your mask. ONLY remove mask after leaving the patient room/area. GLOVES: Outside of gloves are contaminated! Grasp outside of glove with opposite gloved hand; peel off. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist. Peel glove off over first glove. Discard gloves in waste container. FACE SHIELD or GOGGLES: Outside of face shield or goggles is contaminated! To remove, handle by head band or ear pieces. Place in in waste container or designated receptacle for reprocessing. GOWN: The gown front and sleeves are contaminated! Unfasten ties. Pull away from neck and shoulders, touching the inside of gown only. Turn gown inside out. Fold or roll into a bundle and discard. MASK OR RESPIRATOR : Front of mask/respirator is contaminated —DO NOT TOUCH! Grasp bottom, then elastics or top ties and remove. Discard in waste container. PERFORM HAND HYGIENE IMMEDIATELY AFTER REMOVING ALL PPE

    Dedicate equipment to patients on precautions if at all possible Clean equipment between patient use (even your stethoscope!) Covers do not eliminate the need for careful cleaning (i.e. gloves for hands; hygie bags for commode pots, etc.)

    Dedicate equipment to patients on precautions if at all possible Clean equipment between patient use (even your stethoscope!) Offer residual personal care supplies that you’re going to throw out to the patient to use at home

    Disinfectant should have basic influenzacidal claim on label Avoid use of vacuum cleaners however, i f a vacuum must be used, ensure it’s hepa-filtered Use dedicated or single-use disposable cleaning equipment When non-disposable equipment is used (i.e. mop heads) this equipment must be laundered after use through an institutional/industrial laundry Housekeeping staff must wear appropriate PPE for the area Discharge Clean: bed space or cubicle must be cleaned regularly. Special attention to dust collecting areas, horizontal surfaces, and frequently touched items. Bedside curtains must be changed. Supplies stored in the bed space must be discarded. Housekeeping checklist must be used in patient/residential areas. Standard practices for handling & reprocessing used & soiled patient care equipment, including re-usable medical devices, must be performed for both influenza and non-influenza areas .

    Influenza virus is excreted through stool & urine for several days or weeks after patient is well however, at this time routine practices are sufficient as PPE is worn whenever there will be contact with body fluids.

    LTC/Residential Need to consider co-hort areas ER will have a triage plan in place to separate ILI patients from the other patients Signage at entrances will indicate which entrance to use to enter the hospital for ILI patients, need to do hand hygiene and place mask on face Patients needing AGMP will be assigned negative pressure rooms. When these rooms are full patients will be placed in private rooms. When these rooms are full or other patients need private rooms, ILI patients will be co-horted. If surge necessitates, co-hort ILI Units will occur. For any patient with influenza like illness, they should be put on additional infection control precautions known as Droplet Precautions. This includes the donning (wearing) a high quality (which all VIHA masks are) procedural or surgical mask. It must also include the protection of the eyes as they are mucous membranes, and therefore many masks have a shield attached. If not, a face shield or VIHA supplied eye protection must be worn. It is important to remember the 2 metre rule. If moving into the 2 metre space around a patient with respiratory illness droplet precautions are necessary.

    Examples of hospital areas where staff have no patient interaction. Routine practices for these areas include respiratory etiquette and good hand hygiene practices. These practices should be routine for everyone, especially those working in healthcare settings.

    It is important to remember that the risk of acquiring influenza from a patient when passing them in the hallway etc. is very low. A risk in all areas is through contact with contaminated high touch items and areas. This is why respiratory etiquette and hand hygiene so important…….not just in the hospital but everywhere.

    Signage at all entrances to health care settings Separate ILI patients from the others Travel Hx is a standard question for any infection for purposes of Public Health (i.e. f/u and contact tracing)

    Surge, if it happens, will impact all settings and determine how we place patients for maximum efficiencies. Negative pressure rooms for AGMPs Private rooms Co-hort rooms Co-hort Units

    This is for ALL settings. Precautions for 7 days

    Lab Specimens must be done as soon as possible as virus detection diminishes Testing in Acute Care settings is only done on inpatient/admitted patients & some outpatients at Physician direction (currently NP Washes….soon NP swabs…..viral medium with dacron hard plastic shaft or flexible flocked swabs) Testing for H1N1 in Long Term/Residential Care will be ordered by the MRP, and will only be done in the case of outbreak or serious illness in a resident (viral medium & dacron hard plastic shaft or flexible flocked swabs) Testing for H1N1 in Home and Community Care will be determined and ordered by the Family Doctor (viral medium with dacron plastic shaft or flexible flocked swabs) NP washes go to VIHA microbiology and if the test is Influenza A it then needs to go to BCCDC for typing…..this slows the turnaround time When we do NP swabs at VIHA microbiology……turn around will be 24 hours

    Administrative Actions: Reminder calls to check for ILI; defer appts. when ILI present or instruct re mask use on arrival; post signs on doors instructing pts. to report cough/fever; Post signs for respiratory etiquette & hand-hygiene. Physical Barriers: Spatial Separation with glass or acrylic partitions; or by 2 metre/6 ft. space. Mask with attached face visor when space cannot be achieved. Masks, tissues, ABHR, & waste receptacle for people entering facility who have Respiratory symptoms Staff: Observe all patients coming in. All =ABHR. Respiratory symptoms = mask. 2 metres from reception area or place in examining room. Routine practices including 4 key moments of care; etiquette; PPE; don’t touch face. Self-assessments....Do Not work when sick; let supervisor know if they become ill at work; go home if symptomatic. If no replacement available, must wear a mask, perform diligent respiratory etiquette & hand-hygiene until they can be relieved. Gatekeeper Control at Entrances if or when surge occurs. Is there clear signage at the front entrance telling people with respiratory infections what they are supposed to do when coming to your facility? HH & Masks Do staff know how to manage ILI patients they come in contact with at entrance ways...on Units? All facility staff need to understand & practice HH Direct and Indirect care (differences) Masks > Ensure all patients with respiratory symptoms do HH and don a fluid resistant procedure mask, if tolerated , when within 2 metres (i.e. 6 feet) of others HCWs do HH and don a 120mmHg surgical procedure mask with attached face visor when within 6 feet of patients with ILI symptoms & wear PPE Post signs > respiratory etiquette and hand-hygiene for family and others Remove toys and magazines as they cause clutter and inhibit cleaning of the space where they lay which then allows for potential contact exposure to dirty surfaces Minimize all but necessary supplies in patient areas Reduce uneccessary infection from entering the building > Make appointment reminder calls to ensure patient/accompanying family member doesn’t have ILI. If patient has to keep appt. ensure they know which door to enter and provide a mask Pandemic Stockpile supplies are dispersed throughout the island at a specific threshold as supplies are limited, controlled, and under tight security. These will be precious and sought after items should Pandemic ramp up and masses of people suddenly appear at our doors. Managers will be responsible for monitoring and controlling supplies. Lab testing: Admitted patients will have Nasopharyngeal Washes Swabs taken & sent to VIHA lab. Rapid testing will be done on site with results ready in 24 hours. In October VIHA Microbiology will begin molecular testing using Nasopharyngeal swabs. Room placement: inititially sporadic > private Peak > cohort rooms & then Unit During Peak > neg. and private rooms reserved for H1N1 patients with underlying conditions needing AGMP

    There have been questions about quantity of N95 masks and what could happen if we run out….. SHOULD that happen, we would need to move to co-horted Areas/Units and ensure staff working in LTC/Residential, H&CC, and Acute Care that have been fit-tested.

    Annual Seasonal Vaccine Immunization will begin October 13 th . Remember when you get your annual seasonal ‘shot’ outside of VIHA to ask for the name of the vaccine (i.e. Vaxigrip or Flugrip), the lot # and report the date and these details to W&S. H1N1 immunization will likely be given in Nov.

    If you or a member of your family are unwell, or you need advice, these are the numbers to call. If you’re unwell as identified here, you should seek medical advice. If you have to come into hospital and have symptoms of H1N1 influenza, you will be expected to put on a mask.

    When IPCPs are involved, they will notify Public Health (CDC) of suspect or confirmed cases of H1N1

    B. No – people may develop secondary respiratory infections such as a bacterial pneumonia, which will require antibiotics – BUT influenza is not treated with antibiotics because it is a virus.

    All A. Hand hygiene is the single most effective method in preventing transmission of infectious organisms. B, C & D are also relevant and important, as we do not want symptomatic staff at work, and cough etiquette is essential at reducing risk of spread.

    D. When performing aerosol generating medical procedures. These include Aerosol-Generating Medical Procedures (AGMPs): any procedure carried out on a patient that can induce the production of aerosols of various sizes, including droplet nuclei. Examples include: non-invasive positive pressure ventilation (BIPAP, CPAP); endotracheal intubation; respiratory/airway suctioning; high-frequency oscillatory ventilation; tracheostomy care; chest physiotherapy; aerosolized or nebulized medication administration; diagnostic sputum induction; bronchoscopy procedure; autopsy of lung tissue.

    www.viha.ca/h1n1

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    Pandemic Influenza Presentation for Vancouver Island Health Authority Employees - Presentation Transcript

    1. Pandemic Influenza Infection Prevention and Control and Wellness and Safety 2009                                                      
    3. Pre - Quiz
      • When is seasonal influenza in the northern Hemisphere
        • A. Sept – June
        • B. Sept – Jan
        • C. Oct – March
        • D. Dec – March
    4. Pre - Quiz
      • When can you expect pandemic influenza
        • A. Nov – March
        • B. Anytime
        • C. Winter
        • D. Summer
    5. Pre - Quiz
      • When do you wear gloves?
        • A. In the elevator
        • B. In the hospital cafeteria
        • C. When touching something wet and it isn’t yours
        • D. When caring for a pt with influenza
    6. Pre - Quiz
      • When do you need to wear a mask during a pandemic?
        • A. Everywhere in a hospital
        • B. Within 2 meters (6 feet) of a coughing febrile patient
        • C. On a nursing unit with Influenza patients
        • D. Within 2 meters (6 feet) of a patient on precautions for Influenza
    7. Background
      • Spanish 1918 ( H1N1)
      • Asian 1957 (H2N2)
      • Hong Kong 1968 (H3N2 )
    8. Pandemic Phase 6: Sustained Transmission in General Population
    9. Annual Seasonal Epidemics = Antigenic Drift Pandemic = Antigenic Shift Small continuous changes Two different virus strains combine to form a new subtype Predictable Annual Event Winter in Temperate Climates Rare event Some immunity from past exposure No pre-existing immunity Healthy adults usually not at risk for serious complications Healthy people are at risk for serious complications Average deaths 4000 - 7000 Average deaths expected to increase Symptoms Acute Sudden Fever Cough - Runny Nose Muscle Pain Symptoms more severe Complications more frequent Incubation 1 - 4 days Incubation 1 - 7 days Health systems can usually meet public and patient needs Health systems can be overwhelmed Modest Societal Impact Major Societal Impact Adequate supplies of antivirals Antivirals limited Vaccine is available Vaccine unavailable in the early stages
    10. Influenza Viruses
      • Influenza A and B are responsible for most Seasonal Influenza Epidemics
      • They can be broken down into different subtypes identified as H & N
    11. Subtypes
      • Type A includes 15 sub-types of which only 2 ( H1 and H3) are normally associated with widespread epidemics
      • Type B is infrequently associated with regional or widespread epidemics
      • Type C is associated with sporadic cases and minor localized outbreaks
    15. Influenza Identification
      • Acute
      • Respiratory
      • Characterized by: fever, headache, myalgia, prostration, coryza, sore throat, and cough
    16. Differential Diagnosis
      • Common cold
      • Croup
      • Bronchiolitis
      • Viral pneumonia
    17. GI Manifestations
      • Uncommon but sometimes accompany the respiratory phase in children…….and rarely in adults
    18. I nfluenza Characteristics
      • 50% of infections are asymptomatic
      • Viral shedding begins 24 hours before symptoms begin
      • Peak viral shedding on days 1 & 2 ( get lab specimens )
      • H1N1incubation 1-7 days
    19. Influenza Transmission
      • Droplets sprayed from a cough or sneeze
      • Contact ( Direct & Indirect ) from:
      • Contaminated hands
      • Equipment
      • Surfaces
    20. Pandemic H1N1 Influenza High Risk Groups
      • People 15 – 40 years
      • Females
      • Chronic illness (e.g. asthma, diabetes, etc.)
      • Obese
      • Aboriginal
      • Pregnant women in 3 rd trimester
    21. Vaccine and Antivirals
      • H1N1 Vaccine
      • Vaccine Distribution Priority
      • Antiviral National Stockpile
    22. Respiratory Etiquette & Hand Hygiene
      • Cover mouth for coughs
      • Cover nose for sneezes
      • Dispose of used tissues
      • Perform Hand-hygiene
    23. Strict adherence to hand hygiene is the cornerstone of Infection Prevention & Control
    24. Influenza Precautions = Routine Practice +
      • Droplet +
      • Contact
    25. Droplet Precautions for Severe Respiratory Infection with any of the following Dx:
      • Pneumonia
      • Bronchitis
      • Bronchiectasis
      • Acute exacerbation of COPD or Asthma
      • Congestive Heart Failure
      • Myocardial Infarction or Angina
      • Other Lower Respiratory Tract Infection not specified
    26. Routine Practice
      • Routine Practices are to be used at ALL times by ALL HCWs for ALL patient interactions t o reduce the risk of transmission of recognized and unrecognized sources of infection in hospitals.
    27. Hand Hygiene Routine Practice
      • Before touching a patient & between tasks & procedures on the same patient
      • Before performing clean or aseptic procedures
      • After body fluid exposure risk
      • After patient or patient environment exposure
    28. H1N1 Additional Precautions
      • Patient has symptoms of H1N1 ILI and coughing of any intensity:
        • Patient
          • wears a mask with no eye protection
          • encouraged/assisted with hand hygiene
        • Staff
          • Droplet precautions
            • 120 mm Hg Surgical Procedure Mask with attached face visor for eye protection
            • Gloves
            • Gown
    29. H1N1 Additional Precautions
      • Patient has symptoms of H1N1 ILI and forceful cough , and is not willing or able to wear a mask and is not compliant with hand hygiene
        • Staff :
          • Droplet precautions
            • 120 mm Hg Surgical Procedure Mask with attached face visor for eye protection
            • Gloves
            • Gown
      • Potential for indirect contact transmission
      • Plastic and stainless steel
        • Recoverable for > 24 - 48 hours
        • Transferable to hands up to 24 hours
      • Cloth, tissue
        • Recoverable for 8-12 hours
        • Transferable to hands 15 minutes
      • Viable on hands <5 minutes only at high viral titers
      • (Bean B, et al. JID 1982;146:47-51)
      Survival of Influenza Virus
    31. AGMPs
      • Non-invasive positive pressure ventilation (i.e. BIPAP, CPAP)
      • Respiratory or airway suctioning
      • High-frequency oscillatory ventilation
      • Tracheostomy care
      • Chest Physio
      • Aerosolized or nebulized medication administration
      • Diagnostic sputum induction
      • Bronchoscopy procedures
      • Autopsy of lung tissue
    32. Respiratory Protection
      • 120 mm Hg Procedure Surgical Mask
        • Offers high protection from particulate matter and protection from blood and body fluids
        • Suitable for a wide range of clinical procedures where there is a risk of exposure to blood and body fluids or infectious disease
        • Available with attached face shield
    33. Respiratory Protection
      • N95 Mask
        • Rated at 95% filtration efficiency against particles greater than 0.3 microns
        • Single use and latex free
        • An annual fit test is required to ensure correct mask (see Wellness and Safety) as you only wear the mask for which you have passed a fit test
        • Seals against your face to provide protection against airborne microorganisms
    34. Wear the mask for which you were fit-tested
    35. Fluid Resistant Procedure Masks for Patients
      • Fluid resistant mask for patient – 120 mmHg Procedure Surgical Mask with no eye protection
      • CI/NI: MT # 0051157
      • SI: AMS # 40977
    36. Fluid Resistant Procedure Masks for Staff
      • Fluid resistant mask for staff -120 mm Hg Procedure Surgical Mask with attached Face Visor
      • CI/NI: MT # 0004624
      • SI: AMS # 39676
    37. Respiratory Protection
      • Once removed masks are to be immediately discarded
      • N95 masks can be worn by the HCW until it is wet to touch or for as long as 8 hours
      • Gown
      • HH > Mask 120 mm Hg with attached face visor
      • OR
      • HH > AGMP = Fit-tested N95 with full face shield
      • Gloves
      Donning PPE
    39. Gowns
      • Gown area most likely in contact with organism
      • Contaminated:
      • Outside front
      • Clean:
      • Inside, outside back, ties
    40. Mask & Face Shield/Eye Goggles
      • Protects mucous membranes of the eyes, nose, and mouth from splashes or sprays of blood, body fluids, secretions, and excretions during procedures or patient-care activities
    42. Gloves
      • Gloves
      • HH > Full Face Visor/Goggles
      • Gown (ABHR)
      • HH >Mask/Respirator > HH
      Doffing (Removing) PPE
    44. Patient Care Equipment
      • Soiled equipment should be cleaned
      • Handle soiled equipment in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other patients and environments
    45. Patient Care Equipment
      • Reusable equipment in direct contact with the patient must be cleaned and reprocessed before use with another patient
      • Ensure that single-use items are discarded properly.
      • Personal care supplies ( lotions, creams) are not to be shared between patients
    46. Environmental Cleaning & Disinfection
      • Influenza virus is very susceptible to low level disinfectants
      • Daily cleaning with regular industrial cleaning solution
      • Increased attention to high-touch areas within 2 metre/6 foot patient zone
      • Change privacy curtains
    47. Environmental Control
      • Procedures in place for assigning responsibility and accountability for routine cleaning of all patient equipment (schedule established)
      • Commodes/toilets should be cleaned regularly
      • Bedpans reserved for single patient and labelled appropriately
    48. Acute Care Settings
      • Open triage setting in acute care
      • Open cohort areas in hospital
      • Post signs at all entrances informing public of appropriate action to take upon entering hospital
      • Adhere to established policies and procedures for infection control
    49. Precautions – No Patient Interaction
      • Includes: non clinical settings such as medical records, administration, central pharmacy, IT, offices, central maintenance
      • Respiratory etiquette
      • Hand hygiene
      • PHAC Guidance Document May 11, 2009
    50. Precautions – No Direct or Indirect Patient Contact
      • Staff with no direct or indirect patient contact includes those working or traveling in:
        • hallways, cafeterias, public areas, charting rooms, staff lounge, enclosed reception/triage, patient room cleaning, equipment cleaning
      • Precautions required
        • Routine practice
          • Respiratory hygiene
          • Hand hygiene
    51. Precautions - Indirect Patient Contact
      • Includes patient room cleaning, equipment cleaning
      • Respiratory hygiene
      • Hand hygiene
      • Routine practice
      • PHAC Guidance Document May 11, 2009
    52. Precautions - Direct Patient Contact
      • Includes direct patient interaction for all health care providers, porters, non enclosed triage/registration, cleaning patient bedspace while occupied
      • Respiratory hygiene
      • Hand hygiene
      • Routine practice
      • Additional precautions for mask and eye protection
      • PHAC Guidance Document May 11, 2009
    53. Precautions - Direct Patient Contact with Potential for Aerosol Generation
      • Includes endotracheal suctioning and procedures, bronchoscopy, intubation, nebulized therapy, CPR
      • Respiratory hygiene
      • Hand hygiene
      • Glove , Gown
      • N95 mask with full face visors
      • PHAC Guidance Document May 11, 2009
    54. Management of Patients with Suspect or Confirmed H1N1
      • Patient arriving with an ILI
      • Ask patient to wear a mask and perform hand hygiene
      • Triage to a private room or designated space (must be a 2 metre separation from others)
      • Ask for a travel history
      • Virus testing for any hospital acquired respiratory infection, admission from LTC or community with serious respiratory infection
    55. Management of Patients with Suspect or Confirmed H1N1
      • Patient Placement
      • If possible patients with symptoms of ILI should be separated from others without symptoms
      • Placed in a single room
      • Cohorted with another pt with ILI
    56. Management of Patients with Suspect or Confirmed H1N1
      • Keep symptomatic patients in their room until symptoms cease
      • Limit movement of patients including transfers within the facility
    57. Laboratory Testing Acute Care LTC/Residential Care H&CC
      • Specimens must be done as soon as possible during the hospital admission as virus detection diminishes
    58. Care Risk Assessment and Source Control
      • Hospitals
      • Ambulatory Care
      • LTC/Residential Care
      • H&CC
      • Physicians’ Offices/Walk-in Clinics
      • Administrative Actions
      • Physical Barriers
      • Staff Illness
    59. Wellness & Safety
      • W&S should be made aware of staff ILI
      • Staff to contact family physician regarding antivirals
    60. Effectiveness of facemasks & respirators for reducing risk of influenza in community is limited
      • Facemasks for workers in
      • non-healthcare settings not recommended
                                                          
    61. Wellness & Safety
      • Current Priority Fit Testing:
      • Staff providing direct care to patients
      • known or suspected H1N1
      • ER/Admitting Departments
      • ICU
      • Medical Units
      • Units with Negative Pressure Rooms
      • Labor & Delivery
      • H& CC & Residential/LTC (limited #s)
    62. Wellness &Safety
      • Conditions for testing:
      • Clean shaven where the respirator is in contact with the face
      • Only wear the mask for which you were fitted
    63. Wellness & Safety
      • Fit Check
      • Ensure the N95 is worn correctly
      • Performed every time you don an N95 respirator
      • Must be done with clean hands
    64. Wellness & Safety
      • Annual Seasonal Vaccine
      • H1N1 Vaccine
    65. When to Seek Medical Care
      • Call HealthLink BC for advice if you have a fever or cough at:
        • 8-1-1 . If you are unable to dial 8-1-1 from your location, call (604) 215-8110
        • Seek Medical Help if:
      • Temperature 38 degrees or higher
      • And
      • Short of breath, wheezing, very drowsy or confused, have chronic illnesses, are pregnant or if you are concerned
    66. Reporting
      • Health Care Workers must notify:
      • Infection Prevention & Control of all ILI cases
      • Communicable Disease Control
    67. How to protect your patients, your colleagues, your families, & yourself
      • Wash your hands often with soap and water or use a hand sanitizer
      • Cough into a the crook of your arm not your hand
      • Sneeze or cough into a tissue then perform hand hygiene
      • Get immunized when vaccine available
      • Use hand hygiene before and after touching high-touch items (phones, keyboards)
    68. Post Quiz
      • Can Influenza be treated with antibiotics?
        • Yes
        • No
    69. Post Quiz
      • What is the best way to reduce transmission at home or work?
        • A. Hand hygiene
        • B. Staying home
        • C. Respiratory hygiene/cough etiquette
        • D. Immunization
    70. Post Quiz
      • When do we need to use an N95 mask with Pandemic Influenza patients?
        • A. Always
        • B. Within 3 metres
        • C. Within 6 metres of a patient unable/unwilling to mask with a forceful cough
        • D. When performing aerosol generating medical procedures
    71. Additional Resources
      • ·         The most current Canadian numbers of confirmed cases are available at
      • http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/surveillance-eng.php .
      • ·         The most current U.S. numbers of confirmed cases are available at http://www.cdc.gov/h1n1flu/index.htm .
      • ·         The most current international numbers of confirmed cases are available at http://www.who.int/csr/disease/swineflu/updates/en/index.html .
    72. Additional Resources
      • Where I can find more information?
      • ·         Factsheets, resources and updates on the H1N1 flu virus (human swine flu) are available at www.gov.bc.ca/swineflu .
      • ·         Call HealthLink BC at 8-1-1 or visit www.healthlinkbc.ca , 24 hours a day/seven days a week if they have questions/concerns, or if feeling ill
      • ·         Learn how to protect yourself against flu at http://fightflu.ca/index-eng.html .
      • THANK YOU
      • For further information/questions, please contact:
      • Pat Bleackley, Regional Manager
      • VIHA Infection Prevention & Control Program
      • Direct Phone: (250) 739-5962
      • Cell Phone: (250) 713-5729
      • Fax: (250) 739-5934
      • Email: [email_address]
      • Location: Room 2031 NRGH
              • 1200 Dufferin Crescent
              • Nanaimo, BC V9S 2B7
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