Pandemic Influenza:Infection Control Perspectives TOP

Slide 1: Pandemic Influenza:Infection Control Perspectives Division of Healthcare Quality Promotion National Center for Infectious Diseases Centers for Disease Control and Prevention

Pandemic Influenza:Infection Control Perspectives TOP

Slide 2: Pandemic Influenza Image: An old American Red Cross Photo of a body on a stretcher

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Slide 3: Goals of Infection Control Define and identify cases Stop spread of disease In a facility In a population In a geographic region Ensure safety for personnel providing care Confirm effectiveness of practices Prevent inappropriate responses

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Slide 4: Challenges of respiratory pathogens Transmission can occur by respiratory droplets or droplet nuclei- people can get infected simply by coming near infected patients. Symptoms are non-specific- recognition of the infection is often delayed.

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Slide 5: Approaches to controlling transmission are not new either Isolation precautions to prevent the transmission of pathogens in healthcare setting are well established: Standard precautions for all patient interactions. Transmission-based precautions for specific pathogens: Contact precautions Droplet precautions Airborne precautions

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Slide 6: Standard Precautions Constant use of gloves and handwashing (plus face-shields, masks or gowns if splashes are anticipated) for any contact with blood, moist body substances (except sweat), mucous membranes or non-intact skin. Gloves are removed and discarded immediately after completion of a task. Hands are washed every time gloves are removed.

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Slide 7: Contact Precautions For infections spread by direct or indirect contact with patients or patient-care environment (e.g., shigellosis, Ebola hemorrhagic fever, MRSA). Limit patient movement. Private room or room shared with patients with the same infection status. Wear disposable gown and gloves when entering the patient room. Disposable gown and gloves should be removed and discarded inside the patient room. Wash hands immediately after leaving the patient room. Clean patient room daily using a hospital disinfectant, with attention to frequently touched surfaces (bed rails, bedside tables, lavatory surfaces, blood pressure cuff, equipment surfaces). Use dedicated equipment if possible (e.g., stethoscopes)

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Slide 8: Droplet Precautions For infections spread by large droplets generated by coughs, sneezes, etc. (e.g., Neisseria meningitidis, pertussis, influenza). Face shield or goggles, and a surgical mask (not N-95) are worn to prevent droplets reaching the mucous membranes of the eyes, nose and mouth when within 1 meter of the patient. Patients should be separated by 1-2 meters, or be grouped with other patients with the same infection/colonization status. Patient should wear a surgical mask when outside of the patient room. Negative pressure room is not needed.

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Slide 9: Airborne Isolation For infections spread by particles <5µ that remain infectious while suspended in the air (TB, measles, varicella, and variola). Negative pressure room. Surgical mask on patient. N-95 mask for personnel inside negative pressure room. Isolation room air should not be recirculated in the building. Exhaust air away from people, e.g., off the roof.

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Slide 10: Respiratory hygiene/ Cough etiquette 1. Educate staff on the importance of source control measures to prevent transmission of respiratory pathogens, especially during seasonal outbreaks of respiratory illness.

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Slide 11: Respiratory hygiene/ Cough etiquette 2. Post signs instructing persons with symptoms of a respiratory infection to: Cover their nose and mouth when coughing or sneezing, Use and dispose of tissues, and Perform hand hygiene after contact with respiratory secretions.

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Slide 12: Respiratory hygiene/ Cough etiquette 3. Provide tissues and no-touch receptacles for tissue disposal.

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Slide 13: Respiratory hygiene/ Cough etiquette 4. Provide resources and instructions for performing hand hygiene in or near waiting areas.

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Slide 14: Respiratory hygiene/ Cough etiquette 5. During periods of increased rates of respiratory infection or outbreaks, offer masks to those with respiratory symptoms and encourage them to maintain spatial separation from other patients. (Some facilities may find it easier to implement this year round.)

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Slide 15: Other considerations Healthcare personnel are advised to observe droplet precautions when examining and caring for patients with signs and symptoms of a respiratory infection. These measures apply to accompanying family or friends and any other person with respiratory symptoms entering the facility.

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Slide 16: Physical separation Proximity of less than 3 feet has been associated with increased risk for transmission of infections via respiratory droplets. New Engl J Med 1982;307:1255-7 Am J Med 1948;4:690 Increasing distance between infected patients and others may decrease transmission risk.

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Slide 17: Hand hygiene Hand hygiene has been shown to reduce the incidence of respiratory infections in and out of the healthcare setting. Am J Prev Med 2001;21:79-83 Pediatrics 2000;104:738-42 Am J Infect Control 2003;31:364-70

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Slide 18: Contact Transmission? Influenza virus can survive on a variety of surfaces at room temperature and moderate humidity: Steel and plastic: 24-48 hours Cloth and tissues: 8-12 hours. Virus could be transferred from steel to hands 24 hours after inoculation, but from tissue to hands for only 15 minutes.

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Slide 19: Good news Virus could only be recovered on hands for about 5 minutes after inoculation and even then only after contamination with high viral titers. Alcohol based hand rubs have good and rapid activity against influenza.

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Slide 20: Contact Transmission These data are indirect evidence that influenza can be transmitted via contact. However, hand hygiene will easily address this route of transmission.

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Slide 21: Airborne and Droplet What exactly do these terms mean? Droplet transmission: Contagious droplets are propelled a short distance and come into contact with conjunctiva or mucous membranes. Droplets are large (>5 um), travel only a few feet and cannot reach lower airways. Droplets (with infectivity) do not stay suspended in air to travel distances.

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Slide 22: Airborne transmission Production of infectious "droplet nuclei" which can remain suspended in air and travel over distance. Droplet nuclei are smaller, <5um and can travel many feet and can reach lower airways.

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Slide 23: It’s Droplet Droplet precautions have been recommended by HICPAC and employed by healthcare facilities for many years. Some argue that the fact that significant outbreaks are relatively uncommon in acute care settings indicate that most influenza transmission occurs via large droplets.

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Slide 24: It’s Airborne There are several studies that suggest at least some component of airborne transmission.

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Slide 25: So get to the point In reality, there are 3 "types" of influenza we are concerned about. Seasonal, epidemic Avian, non-pandemic Pandemic Currently there are specific infection control recommendations for each one.

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Slide 26: Seasonal Influenza Droplet precautions (plus standard) for the duration of illness. Generally 5 days from symptom onset in adults with normal immune systems. House patients in private rooms with negative air pressure as much as feasible. Private rooms without negative pressure and cohorting are acceptable options. HICPAC Isolation and Nosocomial Pneumonia Guidelines

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Slide 27: Avian flu current recommendations "Patients with a history of travel within 10 days to a country with avian influenza activity and are hospitalized with a severe febrile respiratory illness, or are otherwise under evaluation for avian influenza" In addition to Standard Precautions: Contact Precautions Airborne Precautions Wear eye protection when within 3 feet of the patient.

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Slide 28: Pandemic Influenza Early in a pandemic, it may not be clear that a patient with severe respiratory illness has pandemic influenza. Therefore precautions consistent with all possible etiologies, including a newly emerging infectious agent, should be implemented. This may involve the combined use of airborne and contact precautions, in addition to standard precautions, until a diagnosis is established. (P S4-9, HHS Pandemic Influenza Plan)

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Slide 29: Pandemic Influenza-Established Pandemic Patients with known or suspected pandemic influenza should be placed on droplet precautions for a minimum of 5 days from onset of symptoms.

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Slide 30: Pandemic Influenza-Established Pandemic During procedures that might generate aerosols (bronchoscopy, intubation, suctioning): Airborne Precautions Negative pressure isolation room Particulate respirator (e.g. N95) Contact Precautions Eye Protection

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Slide 31: Pandemic Influenza-Other considerations The addition of airborne precautions, may be considered for strains of influenza exhibiting increased transmissibility, during initial stages of an outbreak of an emerging or novel strain of influenza, and as determined by other factors.

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Slide 32: If “flu is flu” Changing to airborne plus contact precautions will add very little to control efforts since most transmission would still occur via large droplets.

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Slide 33: Conclusions A respiratory hygiene/ cough etiquette strategy will serve as the 1st line of defense against all respiratory pathogens and should be implemented as part of Standard Precautions.

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Slide 34: Conclusions Specific infection control recommendations for pandemic (and avian non-pandemic) influenza will evolve as we learn more. Our infection control strategies must be adaptable.

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Slide 35: Special precautions for high-risk procedures Patient care: -Suctioning -Intubation Laboratory: -Centrifugation -Pipetting

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Slide 36: Practices to Avoid Examples of inappropriate Infection Control practices include: Wearing protective equipment in public areas Failure to discard protective equipment after use Wearing too many protective garments Failure to remove gloves after each task

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Slide 37: Practices to Avoid Inappropriate or random use of Infection Control practices will result in: Confusion and Uncertainty Fear Waste Risk of occupational injury Risk of infection transmission to patients and others

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Slide 38: Special considerations Mechanical devices that may create infections aerosols Oscillating saws Drills Irrigation devices Laser plumes and surgical smoke

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Slide 39: Special considerations Intubation and mechanical ventilation: Appropriate PPE, including eye protection Optimize conditions Consider powered air purifying respirator (PAPR) Breathing circuit filters?

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Slide 40: Special considerations Surgery for patients with airborne pathogens: Postpone if non-emergent Schedule as last case of the day Intubate and extubate in an airborne isolation room Surgical suite air handling: Positive pressure to hallway Personnel inside suite need respiratory protection Personnel outside may need respiratory protection

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Slide 41: Special considerations BSL-4 containment facilities: Distinct from patient care Higher risk than routine clinical laboratory material Concentrated virus Infectious live animals

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Slide 42: Thank You! Image: Person Coughing

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Slide 43: www.cdc.gov/ncidod/hip/isolat/isolat.htm