H1N1 Influenza A Swine Flu

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H1N1 Influenza A Swine Flu

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Title: H1N1 Influenza A Swine Flu

1
H1N1 Influenza A(Swine Flu)

Training for EMS Personnel
May 5, 2009

2
Goal

The goal of this training module for EMS
personnel is guidance and recommendations for
LEMSAs.
We encourage the LEMSAs to personalize the
implementation of this document for their
specific region.
Coordination among PSAPs, the EMS system,
healthcare facilities (e.g. emergency
departments), and the public health system is
important for a coordinated response to H1N1
Influenza A (swine flu).
Given the uncertainty of the disease, its
treatment, and its progression, the ongoing role
of LEMSA medical directors is critically
important.
The guidance provided in this document is based
on current knowledge of H1N1 Influenza A (swine
flu).

Centers for Disease Control and Prevention (April
29, 2009). Interim Guidance for Emergency Medical
Services (EMS) Systems and 9-1-1 Public Safety
Answering Points (PSAPs) for Management of
Patients with Confirmed or Suspected Swine-Origin
Influenza A (H1N1) Infection. Retrieved May 1
2009 from http//www.cdc.gov/h1n1flu/guidance_ems.
htm
3
Topics

What is H1N1 Influenza A (swine flu)?
What the current status of its incidence is in
California
Definition of Influenza-Like Illness (ILI)
How EMS personnel should approach the care of ILI
patients
Any EMS specific situational guidance
recommendations
Personal Protective Equipment (PPE) availability
and appropriate use
Local surveillance and reporting of ILI for
Public Health and EMS
Recommendations on Cleaning EMS Vehicles
Changes to local EMS policy (LEMSA) for transport
or destinations related to ILI

4
What is H1N1 Influenza A Virus (Swine Flu)?

H1N1 (referred to as swine flu early on) is a
new influenza virus causing illness in people.
This new virus was first detected in people in
April 2009 in the United States.
Other countries, including Mexico and Canada,
have reported people sick with this new virus.
H1N1 Influenza A (swine flu) is transmitted by
respiratory secretions
H1N1 Influenza A (swine flu) is a type of
Influenza-like Illness (ILI)

Centers for Disease Control and Prevention (May
1, 2009). Questions Answers H1N1 Flu (Swine
Flu) and You. Retrieved May 1, 2009
fromhttp//www.cdc.gov/h1n1flu/swineflu_you.htm
5
Why is this New H1N1 virus Sometimes Called
Swine Flu?

This virus was originally referred to as swine
flu because laboratory testing showed that many
of the genes in this new virus were very similar
to influenza viruses that normally occur in pigs
in North America.
But 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 and avian
genes and human genes.
Scientists call this a quadruple reassortant
virus.

The number of cases of H1N1 Influenza A (swine
flu) in California and the world is changing
daily
The nature of disease outbreaks are different
than typical disasters (Earthquakes, Fires,
Floods)
Must be prepared for long term operations
Different local areas may respond differently
based upon the circumstances in their community

Centers for Disease Control and Prevention.
(April 29, 2009). Interim CDC Guidance for
Nonpharmaceutical Community Mitigation in
Response to Human Infections with Swine Influenza
(H1N1) Virus. Retrieved May 1, 2009 from
http//www.cdc.gov/h1n1flu/mitigation.htm
7
Can Humans Catch H1N1 Influenza A (swine flu)?

Cases of human infection with this H1N1 Influenza
A virus were first confirmed in the United States
in Southern California and near Guadalupe County,
Texas additionally, the outbreak intensified
rapidly from that time and more and more states
have been reporting cases of illness from this
virus.
CDC and local and state health agencies are
working together to investigate this situation.
CDC has determined that this new H1N1 Influenza A
virus is contagious and is spreading from human
to human however, at this time, it is not known
how easily the virus spreads between people.

Centers for Disease Control and Prevention (May
1, 2009). Questions Answers H1N1 Flu (Swine
Flu) and You. Retrieved May 1, 2009
fromhttp//www.cdc.gov/h1n1flu/swineflu_you.htm
8
What are the Signs Symptoms of H1N1 Influenza A
in Humans?

The symptoms of this new influenza A H1N1 virus
in people are similar to the symptoms of regular
human flu and include fever (greater than 100.0º
F or 37.8 º C), cough, sore throat, body aches,
headache, chills and fatigue.
A significant number of people who have been
infected with this virus also have reported
diarrhea and vomiting.
Also, like seasonal flu, severe illnesses and
death has occurred as a result of illness
associated with this virus.

Human-to-human transmission of H1N1 Influenza A
predominantly occurs through direct droplet
transmission (Usually within 6-10 feet).
This is thought to occur in the same way as
seasonal flu, which is mainly person-to-person
transmission through coughing or sneezing of
infected people.
People may become infected by touching something
with flu viruses on it and then touching their
mouth or nose (moist mucous membranes).

At the current time, CDC believes that this virus
has the same properties in terms of spread as
seasonal flu viruses.
With seasonal flu, studies have shown that people
may be contagious from one day before they
develop symptoms to up to 7 days after they get
sick.
Children, especially younger children, might
potentially be contagious for longer periods.
CDC is studying the virus and its capabilities to
try to learn more and will provide more
information as it becomes available.

Centers for Disease Control and Prevention (May
1, 2009). Questions Answers H1N1 Flu (Swine
Flu) and You. Retrieved May 1, 2009
fromhttp//www.cdc.gov/h1n1flu/swineflu_you.htm
11
How Can Someone with the H1N1 Influenza A Infect
Someone Else?

Droplets from a cough or sneeze of an infected
person move through the air.
Germs can be spread when a person touches
respiratory droplets from another person on a
surface like a desk and then touches their own
eyes, mouth or nose before washing their hands.
Infected people may be able to infect others
beginning 1 day before symptoms develop up to 7
or more days after becoming sick.

Wash your hands.
Try to stay in good general health.
Get plenty of sleep, be physically active, manage
your stress, drink plenty of fluids, and eat
nutritious food.
Try not touch surfaces that may be contaminated
with the flu virus.
Avoid close contact with people who are sick.

Persons with H1N1 Influenza A (swine flu) 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.

Non-hospitalized ill persons who are a confirmed
or suspected case of swine-origin influenza A
(H1N1) virus infection are recommended to stay at
home (voluntary isolation) for at least the first
7 days after checking with their health care
provider about any special care they might need
if they are pregnant or have a health condition
such as diabetes, heart disease, asthma, or
emphysema.
CDC guidance on care of patients at home can be
found at http//www.cdc.gov/h1n1flu/guidance_homec
are.htm

As a component of the nations critical
infrastructure, emergency medical services (along
with other emergency services) play a vital role
in responding to requests for assistance,
triaging patients, and providing emergency
treatment to influenza patients.
However, unlike patient care in the controlled
environment of a fixed medical facility,
prehospital EMS patient care is provided in an
uncontrolled environment, often confined to a
very small space, and frequently requires rapid
medical decision-making, and interventions with
limited information.
EMS personnel are frequently unable to determine
the patient history before having to administer
emergency care.

If there HAS NOT been H1N1 Influenza A virus
reported in the geographic area
(http//www.cdc.gov/h1n1flu/), 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 ILI

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 H1N1
Influenza A (swine flu) 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 H1N1 Influenza A (swine flu)
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 H1N1
Influenza A (swine flu).

19
Local Surveillance Reporting of ILI for Public
Health EMS

Follow the policies of the local EMS agency
(LEMSA) regarding surveillance reporting of ILI
patients.
This may include reporting suspected incidences
of ILI to
Facility staff at the patient transport
destination
Your supervisor
Should include documentation on the Pre-Hospital
Patient Care Report (PCR) of your significant
findings

20
Interim Recommendations for Assessment of
Influenza-Like Illness (ILI)

If the HAS CDC confirmed H1N1 Influenza A (swine
flu) in the geographic area http//www.cdc.gov/h1n
1flu/
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
H1N1 Influenza A (swine flu) 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 H1N1 Influenza A (swine
flu).

Centers for Disease Control and Prevention.
(April 29, 2009). Interim Guidance for Emergency
Medical Services (EMS) Systems and 9-1-1 Public
Safety Answering Points (PSAPs) for Management of
Patients with Confirmed or Suspected Swine-Origin
Influenza A (H1N1) Infection. Retrieved May 1,
2009 from http//www.cdc.gov/h1n1flu/guidance_ems.
htm
21
Interim Recommendations for Assessment of
Influenza-Like Illness (ILI)

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 H1N1
Influenza A (swine flu) if not already on.

EMS Personnel should ensure that they have the
necessary personal protective equipment
N95 mask, surgical masks, gloves, eye protection,
gown, and other standard equipment for droplet
precautions
EMSA 216 Policy for PPE
Sufficient Types Quantities of PPE should be
evaluated based upon local EMS policy

Centers for Disease Control and Prevention.
(April 29, 2009). Interim Guidance for Emergency
Medical Services (EMS) Systems and 9-1-1 Public
Safety Answering Points (PSAPs) for Management of
Patients with Confirmed or Suspected Swine-Origin
Influenza A (H1N1) Infection. Retrieved May 1,
2009 from http//www.cdc.gov/h1n1flu/guidance_ems.
htm
23
Personal Protective Equipment (PPE)Interim
Recommendations

When treating a patient with a suspected case of
H1N1 Influenza A (swine flu) 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 and ventilation to reduce the
concentration of aerosol accumulation when
possible.
EMS agencies should always practice basic
infection control procedures including
vehicle/equipment decontamination, hand hygiene,
cough and respiratory hygiene, and proper use of
FDA cleared or authorized medical personal
protective equipment (PPE).

Pending clarification of transmission patterns
for this virus, EMS personnel who are in close
contact with patients with suspected or confirmed
H1N1 Influenza A (swine flu) cases should wear a
fit-tested disposable N95 respirator, disposable
non-sterile gloves, eye protection (e.g.,
goggles eye shields), and gown, when coming into
close contact with the patient.

All EMS personnel engaged in aerosol generating
activities (e.g. endotracheal intubation,
nebulizer treatment, treatments involving
respiratory secretions, and resuscitation
involving emergency intubation or cardiac
pulmonary resuscitation) should wear a fit-tested
disposable N95 respirator, disposable non-sterile
gloves, eye protection (e.g., goggles eye
shields), and gown
Unless EMS personnel are able to rule out acute
febrile respiratory illness or travel to an
endemic area in the patient being treated.

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

When possible, safely utilize the manufacturers
recommendations for removal of PPE.
In the event that the manufactures information
is not available or the combination of PPE does
not allow for safe removal of PPE this process
could serve as a guide.
The guide may need modification due to equipment
variations or contamination patterns.
When removing PPE make every attempt to avoid
contact with contaminated areas and wash hands
before touching a clean area.

Gloves
Face shield or goggles
Gown
Mask or respirator

Centers for Disease and Prevention, (May 20,
2004). Guidance for the Selection and Use of
Personal Protective Equipment (PPE) in Healthcare
Settings. Retrieved May 1, 2009 from
http//www.cdc.gov/ncidod/dhqp/ppe.html
31
How to Remove Gloves

Grasp outside edge near wrist
Peel away from hand, turning glove inside-out
Hold in opposite gloved hand

Slide ungloved finger under the wrist of the
remaining glove
Peel off from inside, creating a bag for both
gloves
Discard in approved biomedical waste container

Grasp ear or head pieces with ungloved hands
Lift away from face
Discard in approved biomedical waste container

Unfasten ties
Peel gown away from neck shoulder
Turn contaminated outside toward the inside
Fold or roll into a bundle
Discard in approved biomedical waste container

Untie the bottom, then top, tie
Remove from face
Discard in approved biomedical waste container

Lift the bottom elastic over your head first
Then lift off the top elastic
Discard in approved biomedical waste container

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
Ensure that hand hygiene facilities are available
at the point needed (sink or alcohol-based hand
rub)

EMS personnel involved in the interfacility
transfer of patients with suspected or confirmed
H1N1 Influenza (swine flu) should use standard,
droplet and contact precautions for all patient
care activities.
This should include wearing a fit-tested
disposable N95 respirator, wearing disposable
non-sterile gloves, eye protection (e.g.,
goggles, eyeshield), and gown, to prevent
conjunctival exposure.
If the transported patient can tolerate a
facemask (e.g., a surgical mask), its use can
help to minimize the spread of infectious
droplets in the patient care compartment.

Encourage good patient compartment vehicle
airflow/ ventilation to reduce the concentration
of aerosol accumulation when possible.
If the transported patient can tolerate a
facemask (e.g., a surgical mask), its use can
help to minimize the spread of infectious
droplets in the patient care compartment.
Encourage good patient compartment vehicle
airflow/ ventilation to reduce the concentration
of aerosol accumulation when possible.

The following are general guidelines for cleaning
or maintaining EMS transport vehicles and
equipment after transporting a suspected or
confirmed H1N1 Influenza A (swine flu) patient.
This guidance may be modified or additional
procedures may be recommended by the Centers for
Disease Control and Prevention (CDC) as new
information becomes available.

Routine cleaning with soap or detergent and water
to remove soil and organic matter, followed by
the proper use of disinfectants, are the basic
components of effective environmental management
of influenza.
Reducing the number of influenza virus particles
on a surface through these steps can reduce the
chances of hand transfer of virus.
Influenza viruses are susceptible to inactivation
by a number of chemical disinfectants readily
available from consumer and commercial sources.

After the patient has been removed and prior to
cleaning, the air within the vehicle may be
exhausted by opening the doors and windows of the
vehicle while the ventilation system is running.
This should be done outdoors and away from
pedestrian traffic.
Routine cleaning methods should be employed
throughout the vehicle and on non-disposable
equipment.

For additional detailed guidance on ambulance
decontamination EMS personnel may refer to
"Interim Guidance for Cleaning Emergency Medical
Service Transport Vehicles during an Influenza
Pandemic" available at http//www.pandemicflu.go
v/plan/healthcare/cleaning_ems.html

When transporting a patient with symptoms of
acute febrile respiratory illness, EMS personnel
should notify the receiving healthcare facility
so that appropriate infection control precautions
may be taken prior to patient arrival.
Patients with acute febrile respiratory illness
should wear a surgical mask, if tolerated.
Small facemasks are available that can be worn by
children, but it may be problematic for children
to wear them correctly and consistently.
Moreover, no facemasks (or respirators) have been
cleared by the FDA specifically for use by
children.

Some local EMS agencies may differ from these
recommendations.
If a conflict arises refer to the LEMSA Medical
Director for clarification

Based upon guidance from the local EMS agency
(LEMSA), future consideration may include changes
to either the decision to transport a patient
under specified circumstances or the destination
Contact your supervisor or local EMS agency
(LEMSA) for information on local transport
considerations.

Antivirals may be used as either a treatment to a
confirmed or suspected case of H1N1 Influenza A
(swine flu) or as prophylactic treatment to
exposed individuals under specified conditions
At this time, prehospital treatment of patients
with antiviral agents is not being utilized
CDC recommends the use of Tamiflu (oseltamivir
phosphate) or Relenza (zanamivir) as part of the
treatment and/or reduction of severity of
infection with swine influenza viruses.
More information on treatment recommendations can
be found at www.cdc.gov/flu/swine/recommendations.
htm

Centers for Disease Control and Prevention.
(April 29, 2009). Interim Guidance on Antiviral
Recommendations for Patients with Confirmed or
Suspected Swine Influenza A (H1N1) Virus
Infection and Close Contacts. Retrieved May 1,
2009 from http//www.cdc.gov/h1n1flu/guidance_ems.
htm
48
Vaccinations

There is no vaccine to protect humans from H1N1
Influenza A (swine flu) at this time.
The seasonal influenza vaccine will likely help
provide partial protection against swine H3N2,
but not swine H1N1 viruses.

Centers for Disease Control and Prevention. (May
2, 2009). Questions Answers Key Facts About
Swine Influenza. Retrieved May 2, 2009 from
http//www.cdc.gov/h1n1flu/guidance_ems.htm
49
Recommendations for Vehicle Decontamination

Upon completion of patient care (single call),
clean all equipment that came in contact with or
was within 6 feet of the suspected ILI patient
with an approved disinfectant.
The equipment may include stretchers, railings,
medical equipment control panels, adjacent
flooring, walls, ceilings and work surfaces, door
handles, radios, keyboards, and/or cell phones.
Cleanse all surfaces within 6 feet of the patient
or surfaces touched by the patient or caregivers
with an approved disinfectant.

Unites States Department of Heath and Human
Services. Interim Guidance for Cleaning Emergency
Medical Service (EMS) Transport Vehicles during
an Influenza Pandemic. Retrieved May 1, 2009 from
http//www.pandemicflu.gov/plan/healthcare/cleanin
g_ems.html2a
50
Recommendations forVehicle Decontamination
(Continued)

Large spills of bodily fluids (e.g., vomit)
should first be managed by removing visible
organic matter with absorbent material.
Place contaminated reusable patient care devices
and equipment in biohazard bags.
Clean and disinfect non-patient-care areas of the
vehicle according to the vehicle manufacturers
recommendations.
Cleaning should be done with detergent and water
and then disinfected using an EPA-registered
hospital disinfectant in accordance with the
manufacturer's instructions.