1. Part II--Understanding the Terminology A “Just-in-Time” Primer on H1N1 Influenza A and Pandemic Influenza provided by the National Association of State EMS Officials Revised June 12, 2009

2. Table of Contents Part I--Understanding Influenza and the Current Influenza Pandemic Part I--Understanding Influenza and the Current Influenza Pandemic Part II--Understanding the Terminology Part II--Understanding the Terminology Part III—Understanding H1N1 Influenza A Part III—Understanding H1N1 Influenza A Part IV—Personal Protective Equipment (PPE) for EMS Part IV—Personal Protective Equipment (PPE) for EMS Part V--Decontamination of Ambulances Part V--Decontamination of Ambulances Part VI—Influenza and EMTALA Part VI—Influenza and EMTALA Part VII– Planning Considerations Part VII– Planning Considerations 6/12/2009National Association of State EMS Officials2

3. Disclaimer This self-learning module was developed by the National Association of State EMS Officials. The content was collated from various sources and current as of June 12, 2009. Users are strongly encouraged to review situational reports and updates from the Centers for Disease Control and Prevention, the US Department of Health and Human Services, the US Department of Agriculture, the World Health Organization, and similar entities as revised and additional information becomes available. NASEMSO did not review or approve material which may have been added beyond the distributed version which is on our web site at www.nasemso.org. This self-learning module was developed by the National Association of State EMS Officials. The content was collated from various sources and current as of June 12, 2009. Users are strongly encouraged to review situational reports and updates from the Centers for Disease Control and Prevention, the US Department of Health and Human Services, the US Department of Agriculture, the World Health Organization, and similar entities as revised and additional information becomes available. NASEMSO did not review or approve material which may have been added beyond the distributed version which is on our web site at www.nasemso.org. www.nasemso.org 6/12/20093National Association of State EMS Officials

4. EMS & 9-1-1 Critical Components of the National Strategy 6/12/20094National Association of State EMS Officials EMS and 9-1-1 documents are available for download at www.ems.gov www.ems.gov

5. Current H1N1 Overview Most people recover from infection without the need for hospitalization or medical care. Most people recover from infection without the need for hospitalization or medical care. Overall, national levels of severe illness from influenza A (H1N1) appear similar to levels seen during local seasonal influenza periods, although high levels of disease have occurred in some local areas and institutions. Overall, national levels of severe illness from influenza A (H1N1) appear similar to levels seen during local seasonal influenza periods, although high levels of disease have occurred in some local areas and institutions. Overall, hospitals and health care systems in most countries have been able to cope with the numbers of people seeking care, although some facilities and systems have been stressed in some localities. Overall, hospitals and health care systems in most countries have been able to cope with the numbers of people seeking care, although some facilities and systems have been stressed in some localities. 6/12/2009National Association of State EMS Officials5

6. UNDERSTANDING THE TERMINOLOGY Part II 6/12/2009National Association of State EMS Officials6

7. What is Swine Flu? Swine flu is NOT a human disease. It is a respiratory illness of pigs caused by a type A influenza virus that regularly causes outbreaks of influenza in pigs. Swine flu is NOT a human disease. It is a respiratory illness of pigs caused by a type A influenza virus that regularly causes outbreaks of influenza in pigs. Swine flu viruses cause high levels of illness and low death rates in pigs. Swine flu viruses cause high levels of illness and low death rates in pigs. Source: CDC at www.cdc.gov/flu/swine/key_facts.htm and www.usda.gov www.cdc.gov/flu/swine/key_facts.htmwww.usda.govwww.cdc.gov/flu/swine/key_facts.htmwww.usda.gov 6/12/20097National Association of State EMS Officials

8. What is Swine Flu? Swine influenza viruses may circulate among swine throughout the year, but most outbreaks occur during the late fall and winter months similar to outbreaks in humans. The classical swine flu virus (an influenza type A H1N1 virus) was first isolated from a pig in 1930. Swine influenza viruses may circulate among swine throughout the year, but most outbreaks occur during the late fall and winter months similar to outbreaks in humans. The classical swine flu virus (an influenza type A H1N1 virus) was first isolated from a pig in 1930. Source: CDC at www.cdc.gov/flu/swine/key_facts.htm and www.usda.gov www.cdc.gov/flu/swine/key_facts.htmwww.usda.govwww.cdc.gov/flu/swine/key_facts.htmwww.usda.gov 6/12/20098National Association of State EMS Officials

9. What is Swine Flu? There is no evidence at this time that swine in the United States are infected with this virus strain and therefore, this is not an animal health or food safety issue. There is no evidence at this time that swine in the United States are infected with this virus strain and therefore, this is not an animal health or food safety issue. Source: CDC at www.cdc.gov/flu/swine/key_facts.htm and www.usda.gov www.cdc.gov/flu/swine/key_facts.htmwww.usda.govwww.cdc.gov/flu/swine/key_facts.htmwww.usda.gov 6/12/20099National Association of State EMS Officials

10. Types of Swine Flu Viruses All influenza viruses change constantly. All influenza viruses change constantly. Over the years, different variations of swine flu viruses have emerged. At this time, there are four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. Over the years, different variations of swine flu viruses have emerged. At this time, there are four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. Most of the recently isolated influenza viruses from pigs have been H1N1 viruses. Most of the recently isolated influenza viruses from pigs have been H1N1 viruses. Source: CDC at www.cdc.gov/flu/swine/key_facts.htm and www.usda.gov www.cdc.gov/flu/swine/key_facts.htmwww.usda.govwww.cdc.gov/flu/swine/key_facts.htmwww.usda.gov 6/12/200910National Association of State EMS Officials

11. How does H1N1 Influenza A spread? Although it is unusual for people to get influenza virus infections directly from animals, sporadic human infections and outbreaks caused by certain avian influenza A viruses and pig influenza viruses have been reported. Although it is unusual for people to get influenza virus infections directly from animals, sporadic human infections and outbreaks caused by certain avian influenza A viruses and pig influenza viruses have been reported. Source: CDC at http://www.cdc.gov/swineflu/key_facts.htm http://www.cdc.gov/swineflu/key_facts.htm 6/12/200911National Association of State EMS Officials

12. How does H1N1 Influenza A Spread Between Species? In general, human infection with flu viruses from pigs are most likely to occur when people are in close proximity to infected pigs, such as in pig barns and livestock exhibits housing pigs at fairs, or environments contaminated with swine flu viruses. In general, human infection with flu viruses from pigs are most likely to occur when people are in close proximity to infected pigs, such as in pig barns and livestock exhibits housing pigs at fairs, or environments contaminated with swine flu viruses. Source: CDC at http://www.cdc.gov/swineflu/key_facts.htm http://www.cdc.gov/swineflu/key_facts.htm 6/12/200912National Association of State EMS Officials

13. How to Define the Current H1N1 Influenza A Outbreak “Swine flu” is a misnomer and should not be used to describe the current H1N1 outbreak in the human population. “Swine flu” is a misnomer and should not be used to describe the current H1N1 outbreak in the human population. The proper name is “H1N1 Influenza A”. The proper name is “H1N1 Influenza A”. The World Health Organization has stopped using the term "swine flu" to avoid confusion over the danger posed by pigs. The World Health Organization has stopped using the term "swine flu" to avoid confusion over the danger posed by pigs. 6/12/200913National Association of State EMS Officials

14. H1N1 or S-OIV “S-OIV” or swine-origin influenza virus is another term currently being used by the CDC although a direct link to a specific swine herd has not been established. “S-OIV” or swine-origin influenza virus is another term currently being used by the CDC although a direct link to a specific swine herd has not been established. The current H1N1 virus causing infection in the population contains genetic fragments from birds, pigs, AND human influenza viruses. The current H1N1 virus causing infection in the population contains genetic fragments from birds, pigs, AND human influenza viruses. 6/12/200914National Association of State EMS Officials

15. H1N1 or S-OIV Further study has shown that this new virus is very different from what normally circulates in North American pigs. Further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia, avian (flu virus) genes, and human (flu virus) genes. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia, avian (flu virus) genes, and human (flu virus) genes. 6/12/2009National Association of State EMS Officials15

16. How could an H1N1 “novel” strain have emerged? Pigs may be infected with influenza A viruses from different species (e.g., ducks and humans) at the same time. Pigs may be infected with influenza A viruses from different species (e.g., ducks and humans) at the same time. This may allow the genes of these viruses to mix, creating new variants of the hemagglutinin and/or neuraminidase proteins on the surface of the virus. This may allow the genes of these viruses to mix, creating new variants of the hemagglutinin and/or neuraminidase proteins on the surface of the virus. If these variants spread to humans, then they would not be recognized by the immune system, and so can cause seasonal epidemics of flu. If these variants spread to humans, then they would not be recognized by the immune system, and so can cause seasonal epidemics of flu. Source: CDC-- www.cdc.gov/flu/about/viruses/transmission.htm www.cdc.gov/flu/about/viruses/transmission.htmwww.cdc.gov/flu/about/viruses/transmission.htm 6/12/200916National Association of State EMS Officials

17. Swine-Origin Influenza Virus (S-OIV) is an H1N1 Influenza A “Novel” Virus “Novel” simply means a “new” strain, one that has not been previously identified in animal or human species. The novel virus contains genetic fragments from birds, pigs, AND human influenza viruses 6/12/200917National Association of State EMS Officials

18. Concerns About the Current H1N1 Strain This (H1N1) outbreak certainly poses the potential to be at least as serious as seasonal flu if not more so. This (H1N1) outbreak certainly poses the potential to be at least as serious as seasonal flu if not more so. Because this is a new (“novel”) virus, most people will not have immunity to it and so illness may be more severe and widespread as a result. Because this is a new (“novel”) virus, most people will not have immunity to it and so illness may be more severe and widespread as a result. The farther the virus spreads, the more chance it will mix, or “reassort” with other flu viruses in circulation and turn into something more lethal. The farther the virus spreads, the more chance it will mix, or “reassort” with other flu viruses in circulation and turn into something more lethal. Source: ScienceNow Daily News at http://sciencenow.sciencemag.org/cgi/content/full/2009/429/1 http://sciencenow.sciencemag.org/cgi/content/full/2009/429/1 6/12/200918National Association of State EMS Officials

19. Updated Info on the Virus Scientists call this a “quadruple reassortant” virus. Scientists call this a “quadruple reassortant” virus. It possesses characteristics of an H1N1 Influenza A viral strain previously identified in 2005. It possesses characteristics of an H1N1 Influenza A viral strain previously identified in 2005. 6/12/2009National Association of State EMS Officials19

20. Updated Info on the Virus The overwhelming majority of cases have been mild and self-limiting, with no need for treatment. The overwhelming majority of cases have been mild and self-limiting, with no need for treatment. Cases of severe or fatal infections have been largely, but not exclusively, confined to people with underlying chronic conditions. Cases of severe or fatal infections have been largely, but not exclusively, confined to people with underlying chronic conditions. 6/12/2009National Association of State EMS Officials20

21. Current Outbreak of H1N1 Influenza A Virus The current outbreak is believed to have started in March 2009. Local outbreaks of an influenza-like illness were first detected in three areas of Mexico, but the virus responsible was not clinically identified as a new strain until April 24, 2009. The current outbreak is believed to have started in March 2009. Local outbreaks of an influenza-like illness were first detected in three areas of Mexico, but the virus responsible was not clinically identified as a new strain until April 24, 2009. Source: Wikipedia at http://en.wikipedia.org/wiki/2009_swine_flu_outbreak http://en.wikipedia.org/wiki/2009_swine_flu_outbreak 6/12/200921National Association of State EMS Officials

22. Updated Info on the Virus Scientists are concerned about possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses, as the normal influenza season in this hemisphere begins. Scientists are concerned about possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses, as the normal influenza season in this hemisphere begins. 6/12/2009National Association of State EMS Officials22

23. Populations at Greatest Risk to H1N1 Flu Related Complications People 65 years and older People 65 years and older Children younger than five years old Children younger than five years old Pregnant women Pregnant women People of any age with certain chronic medical conditions People of any age with certain chronic medical conditions 6/12/2009National Association of State EMS Officials23

24. Definition of Acute Febrile Respiratory Illness A measured temperature 100 degrees Fahrenheit and A measured temperature 100 degrees Fahrenheit and Recent onset of at least one of the following: rhinorrhea or nasal congestion, sore throat, or cough. Recent onset of at least one of the following: rhinorrhea or nasal congestion, sore throat, or cough. Source: CDC at http://www.cdc.gov/swineflu/casedef_swineflu.htm http://www.cdc.gov/swineflu/casedef_swineflu.htm 6/12/200924National Association of State EMS Officials

25. CDC Case Definition of Novel Influenza A (H1N1) Cases A confirmed case --an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests: A confirmed case --an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests: real-time RT-PCR real-time RT-PCR viral culture viral culture Source: CDC at http://www.cdc.gov/swineflu/casedef_swineflu.htm http://www.cdc.gov/swineflu/casedef_swineflu.htm 6/12/200925National Association of State EMS Officials

26. CDC Case Definition of Novel Influenza A (H1N1) Cases A probable case --an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR. A probable case --an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR. Source: CDC at http://www.cdc.gov/swineflu/casedef_swineflu.htm http://www.cdc.gov/swineflu/casedef_swineflu.htm 6/12/200926National Association of State EMS Officials

27. CDC Case Definition of Novel Influenza A (H1N1) Cases A suspected case --an acute febrile respiratory illness with onset: A suspected case --an 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 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 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. resides in a community where there are one or more confirmed cases of S-OIV infection. 6/12/200927National Association of State EMS Officials

28. Common Symptom Set of Current H1N1 Influenza A Virus Fever Fever Cough Cough Body aches Body aches A significant number of people have reported vomiting and diarrhea A significant number of people have reported vomiting and diarrhea 6/12/2009National Association of State EMS Officials28

29. Definition of a Pandemic Pandemic is a worldwide epidemic; an epidemic occurring over a wide geographic area and affecting a large number of people. Pandemic is a worldwide epidemic; an epidemic occurring over a wide geographic area and affecting a large number of people. 6/12/200929National Association of State EMS Officials

30. WHO Pandemic Influenza Phases 6/12/200930National Association of State EMS Officials

31. Stages of an Influenza Pandemic Phase 1-- no viruses circulating among animals have been reported to cause infections in humans. Phase 1-- no viruses circulating among animals have been reported to cause infections in humans. Source: World Health Organization 6/12/200931National Association of State EMS Officials

32. Stages of an Influenza Pandemic Phase 2-- an animal influenza virus circulating among domesticated or wild animals, known to have caused infection in humans. Phase 2-- an animal influenza virus circulating among domesticated or wild animals, known to have caused infection in humans. Phase 3-- an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people (but no human-to- human transmission sufficient to sustain community-level outbreaks). Phase 3-- an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people (but no human-to- human transmission sufficient to sustain community-level outbreaks). Source: World Health Organization 6/12/200932National Association of State EMS Officials

33. Stages of an Influenza Pandemic Phase 4--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. Phase 4--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. Source: World Health Organization 6/12/200933National Association of State EMS Officials

34. Phase 5- Pandemic Is Imminent Characterized by human-to-human spread of the virus into at least two countries in one WHO region. Characterized by human-to-human spread of the virus into at least two countries in one WHO region. 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. 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. The designation of the global pandemic phase will be made by the Director-General of WHO. The designation of the global pandemic phase will be made by the Director-General of WHO. Source: World Health Organization 6/12/200934National Association of State EMS Officials

35. Stage 6-The Pandemic Stage Characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way. Designation of this phase will indicate that a global pandemic is under way. Source: World Health Organization 6/12/200935National Association of State EMS Officials

36. WHO -- Currently at Phase 6 Designation is related to geographic spread. Designation is related to geographic spread. Doesn't mean anything concerning severity of illness caused by the virus. Doesn't mean anything concerning severity of illness caused by the virus. 6/12/2009National Association of State EMS Officials36

37. 6/12/2009National Association of State EMS Officials37 201 Park Washington Court Falls Church, VA 22046 Phone: 703.538.1799 Email: info@nasemso.org