1. PREVENTING TRANSMISSION OF RESPIRATORY INFECTIOUS DISEASES IN CLINICS AND OFFICE SETTINGS BRENDA J. ROUP, PhD, RN, CIC NURSE CONSULTANT IN INFECTION CONTROL MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE

2. TRANSMISSION OF RESPIRATORY INFECTIOUS DISEASES AND INFLUENZA MUSHER, D. HOW CONTAGIOUS ARE COMMON RESPIRATORY TRACT INFECTIONS? NEJM, 348:13, MAR 27, 2003 MUSHER, D. HOW CONTAGIOUS ARE COMMON RESPIRATORY TRACT INFECTIONS? NEJM, 348:13, MAR 27, 2003 TELLIER, R. REVIEW OF AEROSOL TRANSMISSION OF INFLUENZA A VIRUS. EMERGING INFECTIOUS DISEASES, 12:11, NOV. 2006 TELLIER, R. REVIEW OF AEROSOL TRANSMISSION OF INFLUENZA A VIRUS. EMERGING INFECTIOUS DISEASES, 12:11, NOV. 2006

3. TRANSMISSION OF INFLUENZA DEPT OF HEALTH AND HUMAN SERVICES, PANDEMIC INFLUENZA PLAN, 2005, SUPPLEMENT 4, INFECTION CONTROL, OUTPATIENT MEDICAL OFFICES DEPT OF HEALTH AND HUMAN SERVICES, PANDEMIC INFLUENZA PLAN, 2005, SUPPLEMENT 4, INFECTION CONTROL, OUTPATIENT MEDICAL OFFICES http://www.hhs.gov/pandemicflu/plan/ http://www.hhs.gov/pandemicflu/plan/ http://www.hhs.gov/pandemicflu/plan/ http://www.pandemicflu.gov/plan/health care/maskguidancehc.html http://www.pandemicflu.gov/plan/health care/maskguidancehc.html http://www.pandemicflu.gov/plan/health care/maskguidancehc.html http://www.pandemicflu.gov/plan/health care/maskguidancehc.html

4. TRANSMISSION OF INFLUENZA MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE, OFFICE OF PREPAREDNESS AND RESPONSE. MARYLAND PANDEMIC INFLUENZA PLAN, VERSION 6, DECEMBER 2006. MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE, OFFICE OF PREPAREDNESS AND RESPONSE. MARYLAND PANDEMIC INFLUENZA PLAN, VERSION 6, DECEMBER 2006. http://flu.maryland.gov/ http://flu.maryland.gov/ http://flu.maryland.gov/

5. TOPICS 1. TRANSMISSIBILITY/COMMUNICABILITY OF INFLUENZA VIRUS 2. TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT 3. CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT 4. DVD – WHY DONT WE DO IT IN OUR SLEEVES? (www.coughsafe.com) www.coughsafe.com

6. TRANSMISSIBILITY OF INFLUENZA VIRUS REFERS TO THE CAPACITY OF AN INFECTIOUS AGENT TO SPREAD FROM ONE PERSON TO ANOTHER REFERS TO THE CAPACITY OF AN INFECTIOUS AGENT TO SPREAD FROM ONE PERSON TO ANOTHER FOR INFLUENZA VIRUS, DEPENDENT UPON: FOR INFLUENZA VIRUS, DEPENDENT UPON: PARTICLE SIZE AND INFECTIVE DOSE PARTICLE SIZE AND INFECTIVE DOSE SUSCEPTIBILITY OF HOST SUSCEPTIBILITY OF HOST TEMPERATURE, HUMIDITY, AIR CURRENTS, VENTILATION TEMPERATURE, HUMIDITY, AIR CURRENTS, VENTILATION DOWNWIND OR UPWIND DOWNWIND OR UPWIND

7. INFLUENZA VIRUS

8. INFLUENZA VIRUS H & N

9. PANDEMIC INFLUENZA VERY SERIOUS FORM OF INFLUENZA VIRUS THAT MAY CAUSE GLOBAL OUTBREAK VERY SERIOUS FORM OF INFLUENZA VIRUS THAT MAY CAUSE GLOBAL OUTBREAK AN INFLUENZA VIRUS MUST MEET THESE THREE CONDITIONS IN ORDER TO BECOME A PANDEMIC: AN INFLUENZA VIRUS MUST MEET THESE THREE CONDITIONS IN ORDER TO BECOME A PANDEMIC: 1. BE A NEW SUBTYPE OF INFLUENZA VIRUS THAT HAS NOT PREVIOUSLY OR RECENTLY CIRCULATED IN HUMANS 2. CAUSES DISEASE IN HUMANS 3. SUSTAINS HUMAN TO HUMAN TRANSMISSION

10. SNEEZING

11. SNEEZING

12. PARTICLE SIZE OF INFLUENZA VIRUS LARGE DROPLETS (50-100 μm diameter) LARGE DROPLETS (50-100 μm diameter) DO NOT REMAIN SUSPENDED IN AIR DO NOT REMAIN SUSPENDED IN AIR BALLISTIC TRAJECTORY OF A FEW FEET BALLISTIC TRAJECTORY OF A FEW FEET INFECT BY DIRECT CONTACT WITH MUCOUS MEMBRANES OF MOUTH, EYES, UPPER NASAL PASSAGES INFECT BY DIRECT CONTACT WITH MUCOUS MEMBRANES OF MOUTH, EYES, UPPER NASAL PASSAGES

13. PARTICLE SIZE OF INFLUENZA VIRUS INTERMEDIATE SIZE PARTICLES (10-50 μm) INTERMEDIATE SIZE PARTICLES (10-50 μm) TRANSMISSION OF THESE PARTICLES INFLUENCED BY: TRANSMISSION OF THESE PARTICLES INFLUENCED BY: TEMPERATURE OF AIR IN YOUR OFFICE TEMPERATURE OF AIR IN YOUR OFFICE HUMIDITY HUMIDITY AIR CURRENTS AIR CURRENTS AIR VELOCITY AIR VELOCITY REACH UPPER RESPIRATORY TRACT REACH UPPER RESPIRATORY TRACT

14. PARTICLE SIZE OF INFLUENZA VIRUS INCLUDES SMALL PARTICLE AEROSOLS AND DROPLET NUCLEI (<10 μM) INCLUDES SMALL PARTICLE AEROSOLS AND DROPLET NUCLEI (<10 μM) DROPLET NUCLEI = INTERMEDIATE SIZE PARTICLES THAT HAVE DESICATED AND SHRUNK DROPLET NUCLEI = INTERMEDIATE SIZE PARTICLES THAT HAVE DESICATED AND SHRUNK TRANSMISSION PRIMARILY INFLUENCED BY AIR CURRENTS TRANSMISSION PRIMARILY INFLUENCED BY AIR CURRENTS REACH LOWER RESPIRATORY TRACT REACH LOWER RESPIRATORY TRACT

15. SURVIVAL OF VIRUS ON ENVIRONMENTAL SURFACES ON CLOTH OR PAPER = 8 - 10 HOURS ON CLOTH OR PAPER = 8 - 10 HOURS ON NON-POROUS SURFACES (STAINLESS STEEL) = 24 - 48 HOURS ON NON-POROUS SURFACES (STAINLESS STEEL) = 24 - 48 HOURS ON POROUS SURFACES = ?? ON POROUS SURFACES = ??

16. MUSHER, NEJM TRANSMISSION OF INFLUENZA A VIRUS INTRODUCED INTO A VIRUS INTRODUCED INTO A HOME – 50% CLINICAL SYMPTOMS HOME – 50% CLINICAL SYMPTOMS ENCLOSED SPACE OUTSIDE HOME – 50% CLINICAL SYMPTOMS ENCLOSED SPACE OUTSIDE HOME – 50% CLINICAL SYMPTOMS NAVAL CRUISER – 42% CLINICAL SYMPTOMS NAVAL CRUISER – 42% CLINICAL SYMPTOMS AIRPLANE WITH FAILED AIR CIRCULATION SYSTEM – 73% CLINICAL SYMPTOMS AIRPLANE WITH FAILED AIR CIRCULATION SYSTEM – 73% CLINICAL SYMPTOMS

17. TOPICS 1. TRANSMISSIBILITY/ COMMUNICABILITY OF INFLUENZA VIRUS 2. TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT 3. CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT 4. DVD – WHY DONT WE DO IT IN OUR SLEEVES?

18. TRIAGE/SCREENING 1. KEEP YOUR WAITING ROOM AS EMPTY AS POSSIBLE 2. CANCEL NON-ESSENTIAL PATIENT APPTS (EXAMPLE: CHRONIC DISEASE FOLLOW UP) 3. TRAIN FRONT DESK WORKERS IN SCREENING FOR INFLUENZA SYMPTOMS 4. MAXIMUM USE OF TELEPHONE TRIAGE/SCREENING

19. TRIAGE/SCREENING 1. DISCOURAGE VISITS TO OFFICE 2. SEE RESPIRATORY INFECTION PATIENTS AT END OF DAY 3. FRONT DOOR ALERT TO PATIENTS: 1. Please cough or sneeze into your upper sleeve or tissue-throw the tissue into the trash can & wash your hands! 2. If you are coughing & sneezing, please inform the front desk staff! 4. MOVE SYMPTOMATIC PATIENTS INTO EXAM ROOMS AS QUICKLY AS POSSIBLE

20. TOPICS 1. TRANSMISSIBILITY/ COMMUNICABILITY OF INFLUENZA VIRUS 2. TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT 3. CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT 4. DVD – WHY DONT WE DO IT IN OUR SLEEVES?

21. RESPIRATORY HYGIENE/COUGH ETIQUETTE http://www.cdc.gov/flu/professionals/infectioncontrol /resphygiene.htm http://www.cdc.gov/flu/professionals/infectioncontrol /resphygiene.htm http://www.cdc.gov/flu/professionals/infectioncontrol /resphygiene.htm http://www.cdc.gov/flu/professionals/infectioncontrol /resphygiene.htm EMPHASIZES COUGHS AND SNEEZES AND CLEANING OF HANDS EMPHASIZES COUGHS AND SNEEZES AND CLEANING OF HANDS POSTERS IN WAITING AREAS POSTERS IN WAITING AREAS CONSIDER PAMPHLETS HANDED OUT BY RECEPTIONIST (FREE FROM CDC) CONSIDER PAMPHLETS HANDED OUT BY RECEPTIONIST (FREE FROM CDC) IF PATIENT IS ACTIVELY COUGHING, HAND A PROCEDURE MASK (EAR LOOPS) AND MAKE SURE THEY PUT ON IF PATIENT IS ACTIVELY COUGHING, HAND A PROCEDURE MASK (EAR LOOPS) AND MAKE SURE THEY PUT ON

22. MASK WITH EAR LOOPS

23. CONTAINMENT 1. IF PATIENT HAS TO COME TO OFFICE, ONLY ONE PERSON MAY ACCOMPANY THAT PERSON IN THE WAITING ROOM 2. PROVIDE BOXES OF DISPOSABLE TISSUES IN WAITING ROOM, NOT JUST AT RECEPTION WINDOW 3. PLACE LARGE JUGS OF ALCOHOL-BASED HAND CLEANER (60 – 70% ISOPROPYL OR ETHYL ALCOHOL) IN WAITING ROOM 4. PROVIDE AT LEAST ONE CLOSED TRASH CAN WITH FOOT-OPERATED PEDAL

24. CONTAINMENT 5. REMOVE ALL MAGAZINES AND TOYS FROM WAITING ROOM (FOMITES) 6. ASSIGN SOMEONE TO CLEAN HIGH-TOUCH SURFACES EVERY 1-2 HOURS WITH A DISINFECTANT DOOR KNOBS DOOR KNOBS LIGHT SWITCHES LIGHT SWITCHES PENS PENS COMPUTER KEYBOARDS COMPUTER KEYBOARDS TELEPHONES TELEPHONES CHAIR ARMS CHAIR ARMS

25. OFFICE ARRANGEMENT 1

26. OFFICE ARRANGEMENT 2

27. OFFICE ARRANGEMENT 3

28. OTHER CONTAINMENT STRATEGIES CHECK WITH BUILDING MANAGER RE: NUMBER OF AIR EXCHANGES IN OFFICE (12 OR MORE BEST) AND HUMIDITY LEVELS CHECK WITH BUILDING MANAGER RE: NUMBER OF AIR EXCHANGES IN OFFICE (12 OR MORE BEST) AND HUMIDITY LEVELS HIGH AIR FLOW WILL DILUTE INFLUENZA VIRUS AND DESSICATE HIGH AIR FLOW WILL DILUTE INFLUENZA VIRUS AND DESSICATE INCREASED HUMIDITY (>40%) WILL DECREASE VIRUS INFECTIVITY INCREASED HUMIDITY (>40%) WILL DECREASE VIRUS INFECTIVITY

29. N95 RESPIRATORS THERE IS NO RECOMMENDED ROLE FOR THE USE OF N95 RESPIRATORS IN THE OFFICE/CLINIC SETTING THERE IS NO RECOMMENDED ROLE FOR THE USE OF N95 RESPIRATORS IN THE OFFICE/CLINIC SETTING USE THESE OTHER STRATEGIES, ESPECIALLY: USE THESE OTHER STRATEGIES, ESPECIALLY: TELEPHONE TRIAGE TELEPHONE TRIAGE KEEP WAITING ROOM EMPTY KEEP WAITING ROOM EMPTY GET COUGHING PATIENTS INTO EXAM ROOMS QUICKLY GET COUGHING PATIENTS INTO EXAM ROOMS QUICKLY MASK COUGHING PATIENTS MASK COUGHING PATIENTS

30. TOPICS 1. TRANSMISSIBILITY/ COMMUNICABILITY OF INFLUENZA VIRUS 2. TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT 3. CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT 4. DVD – WHY DONT WE DO IT IN OUR SLEEVES? (www.coughsafe.com) DVD – WHY DONT WE DO IT IN OUR SLEEVESwww.coughsafe.com DVD – WHY DONT WE DO IT IN OUR SLEEVESwww.coughsafe.com

31. WEBSITES www.cdc.gov www.cdc.gov www.cdc.gov www.panflu.gov www.panflu.gov www.panflu.gov www.montgomerycountymd.gov/apc www.montgomerycountymd.gov/apc www.montgomerycountymd.gov/apc

32. QUESTIONS www.montgomerycountymd.gov/apc www.montgomerycountymd.gov/apc www.montgomerycountymd.gov/apc

33. STOPTHE SPREAD! This publication was supported by Cooperative Agreement Number U50/CCU302718 from the CDC to NACCHO. Its contents are solely the responsibility of the Montgomery County, Maryland Advanced Practice Center for Public Health Emergency Preparedness and Response and do not necessarily represent the official views of CDC or NACCHO. This publication is in the public domain. It may be reproduced in whole or in part by any individual or organization without permission, as long as the following citation is given: Montgomery County, Maryland Advanced Practice Center for Emergency Preparedness and Response Stop the Spread! A Toolkit for Preventing the Spread of Germs in Clinics and Office Settings. If a part or all of the publication is reproduced, the Montgomery County APC would appreciate knowing how it is used. Please use the form at our website, http://www.montgomerycountymd.gov/apc.