Swine Flu An outbreak of a virulent form of influenza has developed in Mexico. With spring breakers and other travelers cases are popping up like zits on a teenager.

What causes Swine Flu? Swine Flu is a respiratory infection caused by the Influenza A virus. The influenza virus is a primitive virus that affects both mammals and birds.

What is a virus? A virus is a microscopic object that is significantly smaller than a bacterium. Viruses do not contain the cellular stuff to reproduce. Instead, when they enter the cell of a host, they hijack the cell’s biochemical process in order to replicate and produce millions of new viruses.

How many types of influenza are there? There are three major types of influenza virus: Influenza A The most virulent which normally reside in aquatic birds, but have been known to “jump species”, as seen in the current outbreak. Influenza B And Influenza C

What is the current strain? The current swine flu strain in question is H1N1. H1N1 is thought to have caused the Spanish flu in 1918 which killed approximately million people worldwide.

What are the symptoms of swine flu? Fever Cough Sore throat Body aches Headache Chills Fatigue Diarrhea vomiting

What's different with this batch Influenza A is primarily a respiratory virus. The strain of swine flu in Mexico appears to be more virulent than strains seen in the United States. It tends to affect people between 25 and 45 years of age as opposed to the normal strains that affect older adults.

How is Swine flu spread? Mainly person-to-person through coughing or sneezing from infected individuals. Some infections can occur by touching something with flu viruses on it and then touching the mouth or nose.

Slowing the spread Use Standard Precautions Frequent hand washing Use mask when treating patients that are coughing or sneezing. Get plenty of sleep. Maintain adequate nutrition.

How about a vaccine? There is not enough time to develop a vaccine, administer it, and wait for the person’s body to manufacture antibodies for the swine flu.

What's the treatment? Tamiflu or Relenza seem to help with swine flu. The drugs will not prevent infection. Influenza A tends to develop resistance to antiviral agents quickly.

What’s the current who phase As of April 29, 2009 the current World Health Organization pandemic alert is at 4. Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks”. The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion,

Rational behind phase 4 Virus has increased human-to-human transmissibility but is not well adapted to humans and remains highly localized, so that its spread may be possibly be delayed or contained.

Update Mid day April 29 WHO raised the alert to Phase 5 Phase 5 Is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

Rational Virus is more adapted to humans, and therefore more easily transmissible among humans. It spreads in lager clusters, but spread is localized. This is likely to be the last chance for massive coordinated global intervention, targeted to one or more foci, to delay or contain spread.

St. Louis County Health Guidance On April 28 St. Louis County Department of Health issued an alert

Working Case Definition Fever of >=37.8 degrees C (100 degrees F) plus cough or sore throat AND Travel to an area where swine flu is confirmed or contact to a known case

Home Isolation CDC strongly recommends home isolation of cases Persons who develop influenza-like-illness should be strongly encouraged to self-isolate in their home for 7 days after the onset of illness or at least 24 hours after symptoms have resolved.

Medical Care Persons with ILI and wish to seek medical care should contact their medical care provider by phone. Persons who have difficulty breathing or shortness of breath or are believed to be severely ill should seek immediate medical attention.

Infection Control The CDC recommends that standard, droplet, and contact precautions be used for all patient care activities for ILI patients. Maintain hand washing hygiene

Interim Guidance for Emergency Medical Services (EMS) Systems and Public Safety Answering Points (PSAPs) for Management of Patients with Confirmed or Suspected Swine-Origin Influenza A (H1N1) Infection

Infectious Period Persons with swine-origin influenza A (H1N1) virus infection should be considered potentially infectious from one day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might potentially be contagious for longer periods.

Case Definitions for Infection with Swine-origin Influenza A (H1N1) Virus (S-OIV) A confirmed case of S-OIV infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests: 1. real-time RT-PCR 2. viral culture A probable case of S-OIV infection is defined as a person with an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR A suspected case of S-OIV infection is defined as a person with acute febrile respiratory illness with onset within 7 days of close contact with a person who is a confirmed case of S-OIV infection, or within 7 days of travel to community either within the United States or internationally where there are one or more confirmed cases of S-OIV infection, or resides in a community where there are one or more confirmed cases of S-OIV infection.

Recommendations for Public Safety Answering Points (PSAP) It is important for the PSAPs to question callers to ascertain if there is anyone at the incident location who is possibly afflicted by the swine-origin influenza A (H1N1) virus, to communicate the possible risk to EMS personnel prior to arrival, and to assign the appropriate EMS resources. PSAPs should review existing medical dispatch procedures and coordinate any modifications with their EMS medical director and in coordination with their local department of public health. Interim recommendations: PSAP call takers should screen all callers for any symptoms of acute febrile respiratory illness. Callers should be asked if they, or someone at the incident location, has had nasal congestion, cough, fever or other flu-like symptoms. If the PSAP call taker suspects a caller is noting symptoms of acute febrile respiratory febrile illness, they should make sure any first responders and EMS personnel are aware of the potential for “acute febrile respiratory illness” before the responders arrive on scene.

If there HAS NOT been swine-origin influenza reported in the geographic area ( EMS providers should assess all patients as follows: Step 1: EMS personnel should stay more than 6 feet away from patients and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of swine-origin influenza. Step 2: Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: nasal congestion/ rhinorrhea, sore throat, or cough). If no acute febrile respiratory illness, proceed with normal EMS care. If symptoms of acute febrile respiratory illness, then assess all patients for travel to a geographic area with confirmed cases of swine-origin influenza within the last 7 days or close contact with someone with travel to these areas. If travel exposure, don appropriate PPE for suspected case of swine-origin influenza. If no travel exposure, place a standard surgical mask on the patient (if tolerated) and use appropriate PPE for cases of acute febrile respiratory illness without suspicion of swine-origin influenza (as described in PPE section).

If the CDC confirmed swine-origin influenza in the geographic area ( ) Step 1: Address scene safety: If PSAP advises potential for acute febrile respiratory illness symptoms on scene, EMS personnel should don PPE for suspected cases of swine-origin influenza prior to entering scene. If PSAP has not identified individuals with symptoms of acute febrile respiratory illness on scene, EMS personnel should stay more than 6 feet away from patient and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions while assessing all patients for suspected cases of swine-origin influenza. Step 2: Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: nasal congestion/ rhinorrhea, sore throat, or cough). If no symptoms of acute febrile respiratory illness, provide routine EMS care. If symptoms of acute febrile respiratory illness, don appropriate PPE for suspected case of swine-origin influenza if not already on.

Personal protective equipment (PPE): When treating a patient with a suspected case of swine-origin influenza as defined above, the following PPE should be worn: Fit-tested disposable N95 respirator and eye protection (e.g., goggles; eye shield), disposable non-sterile gloves, and gown, when coming into close contact with the patient. When treating a patient that is not a suspected case of swine-origin influenza but who has symptoms of acute febrile respiratory illness, the following precautions should be taken: Place a standard surgical mask on the patient, if tolerated. If not tolerated, EMS personnel may wear a standard surgical mask. Use good respiratory hygiene – use non-sterile gloves for contact with patient, patient secretions, or surfaces that may have been contaminated. Follow hand hygiene including hand washing or cleansing with alcohol based hand disinfectant after contact. Encourage good patient compartment vehicle airflow/ ventilation to reduce the concentration of aerosol accumulation when possible.

All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient.

30 April The situation continues to evolve rapidly. As of 17:00 GMT, 30 April 2009, 11 countries have officially reported 257 cases of influenza A (H1N1) infection.

The United States Government has reported 109 laboratory confirmed human cases, including one death. Mexico has reported 97 confirmed human cases of infection, including seven deaths. The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (19), Germany (3), Israel (2), Netherlands (1), New Zealand (3), Spain (13), Switzerland (1) and the United Kingdom (8).

Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings

PPE Use in Healthcare Settings: Program Goal Improve personnel safety in the healthcare environment through appropriate use of PPE. PPE Use in Healthcare Settings

PPE Use in Healthcare Settings: Program Objectives Provide information on the selection and use of PPE in healthcare settings Practice how to safely don and remove PPE PPE Use in Healthcare Settings

Personal Protective Equipment Definition “specialized clothing or equipment worn by an employee for protection against infectious materials” (OSHA) PPE Use in Healthcare Settings

Regulations and Recommendations for PPE OSHA issues workplace health and safety regulations. Regarding PPE, employers must: –Provide appropriate PPE for employees –Ensure that PPE is disposed or reusable PPE is cleaned, laundered, repaired and stored after use OSHA also specifies circumstances for which PPE is indicated CDC recommends when, what and how to use PPE PPE Use in Healthcare Settings

Hierarchy of Safety and Health Controls Training and administrative controls Engineering controls Work practice controls Personal protective equipment PPE Use in Healthcare Settings

Types of PPE Used in Healthcare Settings Gloves – protect hands Gowns/aprons – protect skin and/or clothing Masks and respirators– protect mouth/nose –Respirators – protect respiratory tract from airborne infectious agents Goggles – protect eyes Face shields – protect face, mouth, nose, and eyes PPE Use in Healthcare Settings

Factors Influencing PPE Selection Type of exposure anticipated –Splash/spray versus touch –Category of isolation precautions Durability and appropriateness for the task Fit PPE Use in Healthcare Settings

Gloves Purpose – patient care, environmental services, other Glove material – vinyl, latex, nitrile, other Sterile or nonsterile One or two pair Single use or reusable PPE Use in Healthcare Settings

Gloves Purpose – patient care, environmental services, other Glove material – vinyl, latex, nitrile, other Sterile or non-sterile One or two pair Single use or reusable PPE Use in Healthcare Settings

Do’s and Don’ts of Glove Use Work from “clean to dirty” Limit opportunities for “touch contamination” - protect yourself, others, and the environment –Don’t touch your face or adjust PPE with contaminated gloves –Don’t touch environmental surfaces except as necessary during patient care PPE Use in Healthcare Settings

Do’s and Don’ts of Glove Use (cont’d) Change gloves –During use if torn and when heavily soiled (even during use on the same patient) –After use on each patient Discard in appropriate receptacle –Never wash or reuse disposable gloves PPE Use in Healthcare Settings

Gowns or Aprons Purpose of use Material – –Natural or man-made –Reusable or disposable –Resistance to fluid penetration Clean or sterile PPE Use in Healthcare Settings

Face Protection Masks – protect nose and mouth –Should fully cover nose and mouth and prevent fluid penetration Goggles – protect eyes –Should fit snuggly over and around eyes –Personal glasses not a substitute for goggles –Antifog feature improves clarity PPE Use in Healthcare Settings

Face Protection Face shields – protect face, nose, mouth, and eyes –Should cover forehead, extend below chin and wrap around side of face PPE Use in Healthcare Settings

Respiratory Protection Purpose – protect from inhalation of infectious aerosols (e.g., Mycobacterium tuberculosis) PPE types for respiratory protection –Particulate respirators –Half- or full-face elastomeric respirators –Powered air purifying respirators (PAPR) PPE Use in Healthcare Settings

Elements of a Respiratory Protection Program Medical evaluation Fit testing Training Fit checking before use PPE Use in Healthcare Settings

For additional information on respirators…. respsars.html PPE Use in Healthcare Settings

PPE Use in Healthcare Settings: How to Safely Don, Use, and Remove PPE

Key Points About PPE Don before contact with the patient, generally before entering the room Use carefully – don’t spread contamination Remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room Immediately perform hand hygiene PPE Use in Healthcare Settings

Sequence* for Donning PPE Gown first Mask or respirator Goggles or face shield Gloves *Combination of PPE will affect sequence – be practical PPE Use in Healthcare Settings

How to Don a Gown Select appropriate type and size Opening is in the back Secure at neck and waist If gown is too small, use two gowns –Gown #1 ties in front –Gown #2 ties in back PPE Use in Healthcare Settings

How to Don a Mask Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with ties or elastic Adjust to fit PPE Use in Healthcare Settings

How to Don a Particulate Respirator Select a fit tested respirator Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with elastic Adjust to fit Perform a fit check – –Inhale – respirator should collapse –Exhale – check for leakage around face PPE Use in Healthcare Settings

How to Don Eye and Face Protection Position goggles over eyes and secure to the head using the ear pieces or headband Position face shield over face and secure on brow with headband Adjust to fit comfortably PPE Use in Healthcare Settings

How to Don Gloves Don gloves last Select correct type and size Insert hands into gloves Extend gloves over isolation gown cuffs PPE Use in Healthcare Settings

How to Safely Use PPE Keep gloved hands away from face Avoid touching or adjusting other PPE Remove gloves if they become torn; perform hand hygiene before donning new gloves Limit surfaces and items touched PPE Use in Healthcare Settings

PPE Use in Healthcare Settings: How to Safely Remove PPE

“Contaminated” and “Clean” Areas of PPE Contaminated – outside front Areas of PPE that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside Clean – inside, outside back, ties on head and back Areas of PPE that are not likely to have been in contact with the infectious organism PPE Use in Healthcare Settings

Sequence for Removing PPE Gloves Face shield or goggles Gown Mask or respirator PPE Use in Healthcare Settings

Where to Remove PPE At doorway, before leaving patient room or in anteroom* Remove respirator outside room, after door has been closed* *Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub PPE Use in Healthcare Settings

How to Remove Gloves (1) Grasp outside edge near wrist Peel away from hand, turning glove inside-out Hold in opposite gloved hand PPE Use in Healthcare Settings

How to Remove Gloves (2) Slide ungloved finger under the wrist of the remaining glove Peel off from inside, creating a bag for both gloves Discard PPE Use in Healthcare Settings

Remove Goggles or Face Shield Grasp ear or head pieces with ungloved hands Lift away from face Place in designated receptacle for reprocessing or disposal PPE Use in Healthcare Settings

Removing Isolation Gown Unfasten ties Peel gown away from neck and shoulder Turn contaminated outside toward the inside Fold or roll into a bundle Discard PPE Use in Healthcare Settings

Removing a Mask Untie the bottom, then top, tie Remove from face Discard PPE Use in Healthcare Settings

Removing a Particulate Respirator Lift the bottom elastic over your head first Then lift off the top elastic Discard PPE Use in Healthcare Settings

Hand Hygiene Perform hand hygiene immediately after removing PPE. –If hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE Wash hands with soap and water or use an alcohol-based hand rub PPE Use in Healthcare Settings *Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub

PPE Use in Healthcare Settings: When to Use PPE

Standard and Expanded Isolation Precautions

Standard Precautions Previously called Universal Precautions Assumes blood and body fluid of ANY patient could be infectious Recommends PPE and other infection control practices to prevent transmission in any healthcare setting Decisions about PPE use determined by type of clinical interaction with patient PPE Use in Healthcare Settings

PPE for Standard Precautions (1) Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated PPE Use in Healthcare Settings

PPE for Standard Precautions (2) Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions PPE Use in Healthcare Settings

What Type of PPE Would You Wear? Giving a bed bath? Suctioning oral secretions? Transporting a patient in a wheel chair? Responding to an emergency where blood is spurting? Drawing blood from a vein? Cleaning an incontinent patient with diarrhea? Irrigating a wound? Taking vital signs? PPE Use in Healthcare Settings

What Type of PPE Would You Wear? Giving a bed bath? Generally none Suctioning oral secretions? Gloves and mask/goggles or a face shield – sometimes gown Transporting a patient in a wheel chair? Generally none required Responding to an emergency where blood is spurting? Gloves, fluid-resistant gown, mask/goggles or a face shield Drawing blood from a vein? Gloves Cleaning an incontinent patient with diarrhea? Gloves w/wo gown Irrigating a wound? Gloves, gown, mask/goggles or a face shield Taking vital signs? –Generally none PPE Use in Healthcare Settings

PPE for Expanded Precautions Expanded Precautions include –Contact Precautions –Droplet Precautions –Airborne Infection Isolation PPE Use in Healthcare Settings

Use of PPE for Expanded Precautions Contact Precautions – Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces) In some instances these are required for entering patient’s environment Droplet Precautions – Surgical masks within 3 feet of patient Airborne Infection Isolation – Particulate respirator* *Negative pressure isolation room also required PPE Use in Healthcare Settings

Hand Hygiene Required for Standard and Expanded Precautions Perform… –Immediately after removing PPE –Between patient contacts Wash hands thoroughly with soap and water or use alcohol-based hand rub PPE Use in Healthcare Settings

PPE Use in Healthcare Settings: Final Thoughts PPE is available to protect you from exposure to infectious agents in the healthcare workplace Know what type of PPE is necessary for the duties you perform and use it correctly

Cleaning EMS Transport Vehicles Clean and disinfect non-patient-care areas of the vehicle according to the vehicle manufacturer’s recommendations.

Non-patient-care areas of the vehicle, such as the driver’s compartment, may become indirectly contaminated, such as by touching the steering wheel with a contaminated glove. Personnel should be particularly vigilant to avoid contaminating environmental surfaces that are not directly related to patient care.

Wear non-sterile, disposable gloves that are recommended by the manufacturer of the detergent/disinfectant while cleaning the patient- care compartment and when handling cleaning and disinfecting solutions. Dispose of gloves if they become damaged or soiled or when cleaning is completed.

Frequently touched surfaces in patient-care compartments (including stretchers, railings, medical equipment control panels, adjacent flooring, walls, ceilings and work surfaces, door handles, radios, keyboards and cell phones) that become directly contaminated with respiratory secretions and other body fluids during patient care, or indirectly by touching the surfaces with gloved hands, should be cleaned first then disinfected.

Non-porous surfaces in patient-care area that are not frequently touched can be cleaned with soap and water.

Clean any small spills of bodily fluids with soap and water followed by disinfectant.

Large spills of body fluids should be picked up with absorbent material then cleaned and disinfected.

Wash hands after cleaning ambulance and equipment.

Dispose of contaminated materials in approved containers.

Thank you