Pandemic Flu and You

1
Pandemic Flu and You

• What healthcare workers need to know

2
BIRD FLU
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Pandemic Influenza

• The Basics

4
FluWhat Are We Talking About?

• Seasonal flu a respiratory illness
• Transmitted person to person
• Most people have some immunity
• Vaccine available
• Avian flu an influenza virus of birds
• Usually does not affect humans
• No human immunity
• No vaccine available
• Pandemic- a global outbreak of disease

5
Avian Flu Has Infected Humans

• Avian flu H5N1 has infected birds in 58
  countries.
• 10 countries have reported human cases.
• Mortality rate is high in human avian flu
  infections

WHO figures, as of 6/24/06
6
What Does the H5N1 Mean?

• Neuraminidase (N)
• 9 types
• Hemagglutinin (H)
• 15 types
• Genes

7
How Can a Bird Flu Cause a Pandemic?

• A new strain of influenza, which can spread
  easily from person to person, could evolve from
  avian flu.
• Mixing of genes from avian flu and human flu
• Mutation of the H5N1 virus
• Humans would have no immunity to a distinctly new
  influenza.

8
Potential Exposure to Avian Fluin Southeast Asia
Is High
9
Global Movement of Humans
?SE ASIA
10
Three Decades Later
? SE ASIA
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Pandemic Impact in King County
CHARACTERISTIC MODERATE (1958/1968 -like) MODERATE (1958/1968 -like) SEVERE (1918 -like) SEVERE (1918 -like)
  U.S. King County U.S. King County
Illness 90 million 540,000 90 million 540,000
Outpatient care 45 million 270,000 45 million 270,000
Hospitalization 865,000 5,190 9,900,000 59,400
ICU care 128,750 773 1,485,000 8,910
Mechanical ventilation 64,875 389 742,500 4,455
Deaths 209,000 1,254 1,903,000 11,418
Adapted from Pandemic Influenza Response Plan,
Public Health Seattle King County,
available _at_ http//www.metrokc.gov/health/pandem
icflu/plan/index.htm
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Current Situation

• Most cases of H5N1 human infection have involved
  direct contact with infected poultry or their
  excretions.
• There is not yet evidence of sustained
  human-to-human transmission.
• Currently, there is no documented highly
  pathogenic H5N1 virus in the Americas.
• There is no pandemic flu at present.

13
WHO Pandemic Flu Phases
             
  WHO PHASES WHO PHASES   U.S. RESPONSE STAGES U.S. RESPONSE STAGES  
  INTER-PANDEMIC PERIOD INTER-PANDEMIC PERIOD INTER-PANDEMIC PERIOD INTER-PANDEMIC PERIOD INTER-PANDEMIC PERIOD  
  1 Influenza virus subtype present in animals.   0 New domestic animal outbreak in atrisk country  
  2 Animal influenza virus subtype poses a substantial risk of human disease.   0 New domestic animal outbreak in atrisk country  
  PANDEMIC ALERT PERIOD PANDEMIC ALERT PERIOD PANDEMIC ALERT PERIOD PANDEMIC ALERT PERIOD PANDEMIC ALERT PERIOD  
  3 Human infection(s) with a new subtype, but no human-to-human spread, or rare instances of spread to a close contact.   0 New domestic animal outbreak in atrisk country  
  3 Human infection(s) with a new subtype, but no human-to-human spread, or rare instances of spread to a close contact.   1 Suspected human outbreak overseas  
  4 Small cluster(s) with limited human-to-human transmission spread is highly localized.   2 Confirmed human outbreak overseas  
  5 Larger cluster(s) but human-to-human spread still localized substantial pandemic risk.   2 Confirmed human outbreak overseas  
  PANDEMIC PERIOD PANDEMIC PERIOD PANDEMIC PERIOD PANDEMIC PERIOD PANDEMIC PERIOD  
  6 Pandemic phase increased and sustained transmission in general population.   3 Widespread human outbreaks overseas  
  6 Pandemic phase increased and sustained transmission in general population.   4 First human case in North America  
  6 Pandemic phase increased and sustained transmission in general population.   5 Spread throughout United States  
  6 Pandemic phase increased and sustained transmission in general population.   6 Recovery and preparation for subsequent waves  
             
?
Table adapted from National Strategy for
Pandemic Influenza Implementation
Plan, Department of Homeland Security, May 2006,
p. 103, available at http//www.whitehouse.gov/hom
eland/nspi_implementation.pdf
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Review Questions 1

• Avian flu is easily transmitted to humans.
• True False
• What phase of the World Health Organizations
  system indicates a pandemic?
• 3. We are currently in what phase?
• 1 2

v
Phase 6
3
16
Government Agencies

• Roles and responsibilities

17
World Health Organization (WHO)

• Monitors global pandemic conditions
• Facilitates enhanced surveillance, response and
  vaccine development
• Declares global pandemic phase

18
Department of Health and Human Services (HHS)

• National guidance on pandemic influenza planning
• Coordination of national response to pandemic
• Determines pandemic response stage for U.S.,
  based on global phase (WHO)

19
Centers for Disease Control and Prevention (CDC)

• Disease control and prevention strategies
• Defines epidemiology of the disease
• Coordinates Strategic National Stockpile
• Coordinates international U.S. travel
  restrictions

20
Washington State Department of Health (WSDOH)

• Coordinates statewide planning surveillance
• CDC Lab Response Network reference lab
• Requests federal assistance, including medication
  from the Strategic National
• Stockpile (SNS)

21
Public Health Seattle King County

• Facilitates countywide planning preparedness
• King County Healthcare Coalition
• Conducts surveillance to track human disease
• Coordinates disease containment strategies
• Manages antiviral and vaccine stockpiles
• Communications to public, healthcare providers,
  media, elected officials, business community
  leaders throughout public health emergency

22
King County Healthcare Coalition

• Collaboration with Public Health and emergency
  management officials to improve emergency
  response across all sectors of the healthcare
  system
• Voluntary organization
• Currently includes 28 healthcare organizations
  agencies
• Open to all health care organizations providing
  services in King County

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Healthcare Coalition Workgroups

• Working Groups
• Acute Care
• Critical Care
• Ambulatory Care
• Medical Directors
• Regional Medical Resource Center

• Future Planning
• Workforce Issues Medical Staffing
• Finance reimbursement
• Long Term Care
• Palliative Care

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Your Facility (add logo, if available)

• Participates in the Healthcare Coalition
• to share information and resources
• to assure communications from Public Health to
  healthcare professionals
• to coordinate operations of health system
• Has developed a pandemic response plan
• Participates in local influenza surveillance
• Has developed infection control plans
• to triage isolate infectious patients
• to protect staff from disease transmission

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Decision-makers

• Who makes decisions re public health?

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Statutory Authority 1

• Governor
• Declare state of emergency
• Restrict public assembly order curfew
• State Board of Health
• Adopt rules
• State Secretary of Health
• Same authority as Local Health Officer, but
  usually defers
• County Executive
• Declare state of emergency within county
• Close any or all businesses, public or private

28
Statutory Authority 2

• Mayor of Seattle and suburban cities
• Declare state of emergency within City
• Direct the use of all public private health
  facilities/equipment for care of injured persons
• Local Health Officer
• Action to control prevent spread of disease,
  including involuntary detention for isolation and
  quarantine (on advice of Chief of Communicable
  Disease Section of Public Health)

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Sick People Are Placed in Isolation

• Isolation Separation and restricted movement of
  ill persons with contagious disease
• Often in a hospital setting
• Primarily individual level, may be applied to
  populations
• Often voluntary, but may be mandatory
• Fundamental, commonly used public health practice

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What Is a Quarantine?

• Separation and restriction of movement of well
  persons presumed to have been exposed to
  contagion
• often at home or residential facility
• may be voluntary or mandatory
• lasts at least as long as the usual incubation
  period of the infectious agent

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Quarantine Statutory Authority 1

• Intrastate quarantine power
• Local or state public health officials have
  authority for quarantine when an infectious
  disease outbreak is confined within state border
• Considered a police power- an inherent authority
  to protect health and welfare of citizens
• Reserved to states (10th Amendment)

32
Quarantine Statutory Authority 2

• Foreign and interstate quarantine
• Considered essential in regulation of foreign and
  interstate commerce
• Federal authority (Commerce Clause)
• Executive decision by the President of U.S.
• CDC manages federal quarantine, with possible
  utilization of assets from other agencies
• CDC may intervene in intrastate incidents if
  requested by state or if local control efforts
  are considered inadequate

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Purpose of Quarantine

• Range of community containment strategies for
  infectious diseases
• Applied to persons exposed but not ill, i.e.,
  contacts (not cases)
• Designed to meet two objectives
• Facilitate early recognition of symptoms of a
  contagious disease, should they develop
• Reduce risk of transmission before progression to
  disease has been recognized

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Community Containment Strategies

• Snow days or shelter-in-place
• Suspension or restrictions on group assembly
• Cancellation of public events
• Closure of mass public transit
• Closing of public places
• Restriction of nonessential travel
• Cordon sanitaire

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Review Questions 2

• Which government agency coordinates the Strategic
  National Stockpile?
• Which official can invoke an order of quarantine?
• A quarantine is separation and restriction of
  movement of well persons.
• True False

Centers for Disease Control Prevention
Local or state health officer
v
36
How Is Influenza Transmitted?
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Modes of Transmission

• Droplets
• Major mode of transmission
• Coughing, sneezing and talking
• Heavy settle within 3 feet of the source
• Contact
• Direct skin-to-skin contact
• Indirect contact with virus in the environment
• Airborne
• Related to procedures?aerosolized particles

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Airborne Transmission

• Endotracheal intubation
• Nebulized meds
• Diagnostic sputum induction
• Bronchoscopy
• Airway suctioning
• Tracheostomy care
• Chest physiotherapy

• Nasopharyngeal aspiration
• CPAP
• High-frequency oscillatory ventilation
• Resuscitation maneuvers
• Postmortem excision of lung tissue

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Influenza The Survivor

• Influenza virus has been shown to survive
• lt24-48 hours on nonporous surfaces
• lt8-12 hours on cloth, paper and tissues
• On hands for up to 5 minutes
• Virus can be transferred
• From nonporous surfaces to hands for 24 hr.
• From paper tissues to hands for 15 min.

Bean B et al. J Infect Dis. 1982 46 47-51
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British Columbia Ministry of Health _at_
www.health.gov.bc.ca/pandemic/tools.htmlpublicati
ons
41
British Columbia Ministry of Health _at_
www.health.gov.bc.ca/pandemic/tools.htmlpublicati
ons
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Protect Yourself and Others

• Eat healthy foods, get enough sleep, exercise
• Wash your handsoften!
• Try not to touch your eyes, nose or mouth
• Stay away from people who are sick
• Avoid public gatherings and crowds
• Get a seasonal flu shot each year
• Call your doctor before visiting the office when
  you are sick

43
British Columbia Ministry of Health _at_
www.health.gov.bc.ca/pandemic/tools.htmlpublicati
ons
44
What About Masks?

• Surgical and procedure masks
• Protect against large particles, such as mucous
  and saliva expelled with a cough
• Do not protect against aerosolized virus
• May provide a false sense of security
• Respiratory etiquette and hand hygiene remain
  essential practices
• May help contain respiratory secretions when worn
  by an individual with flu symptoms

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Antiviral Medication 1

• Neuraminidase inhibitors
• Oseltamivir (Tamiflu)
• pill suspension
• FDA-approved for prevention treatment
• Zanamivir (Relenza)
• Inhaler
• FDA-approved for reducing severity duration of
  symptoms
• Both medicines will be available in the Strategic
  National Stockpile (SNS)

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Antiviral Medication 2

• Reality-testing
• May not be effective in prevention or treatment
  of pandemic flu strain
• Virus may develop resistance
• Larger dose may be necessary
• Should be administered within 48 hours of onset
  of illness to be most effective
• Supply is limited
• Will be generally designated for treatment of
  illness
• Use will be prioritized according to risk
  categories

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Antiviral Supply Is Limited
Strategic National Stockpile

• King County
• 4.7 million allocated for purchase by County
  Executive
• Order placed with Roche Laboratories
• Negotiations re bulk purchase pricing through
  State of Washington ongoing

DHHS Pandemic Planning Update II _at_
http//www.pandemicflu.gov/plan/pdf/PanfluReport2.
pdf
48
Healthcare Workers Are Priority

• Antiviral drug priority groups 1 2, as
  recommended by National Vaccine Advisory
  Committee (NVAC)
• Group 1 Patients admitted to hospital
• Group 2 Healthcare workers with direct patient
  contact and EMS providers

DHHS Pandemic Influenza Plan _at_ www.hhs.gov/pandemi
cflu/plan/appendixd.html
49
Stockpiling Not Recommended

• Current supply of Tamiflu is inadequate to meet
  demand worldwide in a pandemic
• Misuse of antivirals can contribute to increasing
  viral resistance
• Groups of people designated at most risk for
  serious illness and with most need for antivirals
  will depend on the epidemiology of the pandemic
  strain

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What About Vaccine?

• Challenges
• Production technology
• Egg-based
• Cell-based
• Production capacity and costs
• Nailing down the pandemic viral strain
• Reality
• 3-6 months until 1st doses available
• Months for enough to cover high-risk groups
• ?Healthcare workers are in Priority Group 1

51
Review Questions 3

• Influenza is transmitted via
• a. droplets
• b. contact
• c. aerosolized particles
• d. all of the above
• 2. What is the major mode of transmission?
• 3. Antiviral medication may not be effective in
  treatment of a pandemic flu strain.
• True False

Droplets
v
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Pandemic Flu and Your Job

• Healthcare workers on the front line

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Get Prepared at Home

• Store extra supplies
• water, food, health supplies
• Get an extra supply of prescription drugs
• Create a list of your familys health information
• Plan for childcare and/or eldercare, when schools
  and daycare centers close
• plan for home-bound activities and recreation
• Plan for possible reduction of income
• Consider transportation alternatives

54
Get Prepared at Work

• Get a seasonal influenza vaccination!
• Clarify ahead of time
• job expectations during a pandemic
• possibility of alternate work assignments for
  employees who are at high-risk medically
• hospital policies for absenteeism, leave,
  compensation
• training opportunities, protocols, PPE

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Personal Emergency Planning for Workplace

• Personal emergency contact information
• Identification of care givers contact info
• for children
• for elders
• for pets
• Personal medication list
• Emergency supply of meds at work
• Other essential info necessary when requested
• to report to duty or
• to remain at work during a disaster

56
Clarify Absenteeism Policies

• Not showing up/not calling in
• Refusing to work
• Not completing shift (unrelated to illness)
• Coming to work late
• plus
• Knowingly coming to work ill

57
Clarify Leave Policies

• Personal illness
• Family member illness
• School closure
• Extended medical leave
• Bereavement leave
• Closure of your facility
• Hospital-imposed quarantine
• Social distancing as non-essential personnel

58
Clarify Compensation Policies

• Compensation tied to absenteeism and leave
  policies
• Overtime pay
• Extended shift lengths
• (Other)

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Clarify Employment Policies

• Cancellation of vacations
• Approval of overtime
• Redeployment of staff
• Use of part-time or retired staff
• Contracting out
• Temporary staff
• Work assignments for healthcare workers at high
  risk for complication of flu

60
Clarify Employee Services

• Mental health, stress counseling, social services
  for staff and family
• (Provide list of resources)
• Educational materials in different languages, as
  needed
• Emergency Assistance Program (EAP)
• Plans (if any) to house essential staff
• (Other)

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Patient CareWhat Do I Wear?
62
Lessons Learned from SARS

• Transmission of SARS to healthcare workers was
  associated with
• lack of infection control precautions
• inconsistent use of PPE
• having lt2 hours of infection control training
• procedures ? aerosolized particles without
  required use of fit-tested N-95 equivalent
• job as non-medical support staff

Lau JTF et al. Emerging Infectious Diseases.
August 2004 10 (8) 1399-1404. Seto WH et al.
The Lancet. May 3, 2003 361 1519-20.
63
Personal Protection Equipment (PPE) for Direct
Patient Contact

• Seasonal influenza
• Standard droplet precautions at minimum
• Suspected avian H5N1 influenza
• when working within 3 ft. of patient
• during aerosol-generating procedures
• Standard, contact, airborne eye protection
• Pandemic flu virus
• recommendations to be determined

Influenza A (H5N1) WHO Interim Infection Control
Guideline for Health Care Facilities
64
Standard Precautions

• Hand hygiene
• Before and after each patient contact
• After removing gloves or any PPE item
• After using the restroom
• Soap and water (for at least 15 seconds)
• When hands are visibly soiled or contaminated
  with proteinaceous material, like blood
• Use single-use towel for drying hands turning
  off water faucet.
• Alcohol-based hand rub

65
Contact Precautions

• Gloves
• Gown
• Foot protection (no sandals)
• Mask
• Eye protection goggles or face shield
• Dedicated or disposable equipment
• Appropriate handling of soiled linen, patient
  care equipment, waste

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Droplet Precautions

• Private room or cohorting
• 3 ft. between beds
• Surgical or procedure mask
• recommended when entering room
• mandatory if working within 3 feet of patient
• Limit transport of patient
• Surgical mask on patient when transported

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Airborne Precautions

• Airborne infection isolation (negative pressure)
  room
• Use fit-tested respirator upon entry
• at least as protective as NIOSH-certified N-95
• respiratory protection program, including
  training, fit-testing and seal-testing

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Putting On PPE(WHO suggested sequence)

1. Shoe covers, if used
2. Hand hygiene (alcohol-based preferable)
3. Gown
4. Mask or particulate respirator
5. Hair cover, if used
6. Eye protection face shield or goggles
7. Gloves (cover cuff of gown sleeves)

• WHO

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Taking It Off(WHO suggested sequence)

• To prevent self-contamination or self-inoculation
  with contaminated PPE
• Shoe covers
• Protective eyewear
• Hair cover
• Gown
• Gloves (peel from hands along with gown)
• Hand hygiene (alcohol-based preferable)
• Mask or particulate respirator (do not touch
  front)
• Hand hygiene

• WHO

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Environmental Infection Control

• Waste disposal
• Standard Precautions for infectious waste
• Close the toilet lid when flushing
• Linen and laundry
• Standard Precautions
• Gloves, followed by hand hygiene
• Prevent contamination of clothing
• Do not shake soiled linen to avoid contamination
  of the environment

www.cdc.gov/ncidod/dhqp/gl_environinfection.html
72
Protocols for Protection

• Donning and removing PPE
• Safe handling of contaminated PPE
• Managing unprotected staff areas
• Monitoring staff health
• Quarantine of staff
• Transport of patients
• High-risk use of respiratory equipment
• Visiting policies
• Cleaning and disinfecting equipment/environment

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Pocket Cards for EMS

• INFECTIOUS DISEASE
• PREVENTION
• HANDWASHING
• Hand washing is the most effective way to prevent
  transmission of Infectious Disease.
• WASH HANDS
• After patient contact
• Before eating, drinking, smoking or handling food
• Before after using the bathroom
• After cleaning or checking equipment
• PPE
• Gloves and Eye Protection should be worn for
  every patient.
• FULL PPE for possible Infectious contacts
• Donning Sequence
• Gloves gt Gown or Suit gt Mask gt Eye Protection

• INFECTIOUS DISEASE
• FEBRILE ILLNESS
• Dispatchers will notify units of -
  Infectious symptoms or locations
• Dispatch info or fever w/ cough or illness
  or possible infectious disease
• FULL PPE
• Gloves, Eye Protection, HEPA Masks Gowns or
  Suit
• Mask patient
• Limit patient contacts
• After patient contact
• Remove PPE approved sequence
• Dispose of PPE as contaminated waste
• On scene decon - Eye Protection equipment w/
  germicidal cleaner
• Hospital decon - Eye Protection, equipment and
  apparatus

74
Review Questions 4

• Transmission of SARS to HCWs was associated with
  inadequate training.
• True False
• Hand hygiene should be performed
• a. before and after each patient contact
• b. after removing gloves or other PPE
• c. after using the restroom
• d. all of the above
• When hands are contaminated with blood, clean
  with alcohol-based hand rub.
• True False

v
v
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Influenza Preparedness Plan

• (your facilitys name)

76
Elements of the Influenza Plan

• Surveillance plan
• Communication plan
• Education and training plan
• Triage and admission plan
• Facility access plan
• Occupational health plan
• Issues related to surge capacity

Influenza preparedness coordinator (name)________
_________________________
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Surveillance

• Syndromic surveillance in ED
• Criteria to distinguish pandemic flu
• System for internal review of pandemic flu
  activity in patients presenting to ED
• Individual designated to monitor public health
  advisories
• (name or title) _________________________
• System for monitoring nosocomial transmission of
  seasonal influenza (preparation for pandemic flu
  monitoring)

78
Communications

• Clinical spokesperson for our facility
• (name)____________________________
• Media spokesperson for our facility
• (name)____________________________
• Daily updates to key facility personnel
• (name)____________________________
• Washington State Dept. of Health contact
• (name/contact info)___________________
• King County Public Health contact
• (name/contact info)____________________

79
Communications

• Updates to patients and visitors re pandemic flu
  activity level
• (Components of plan)
• Regular situation updates to ED, clinical and
  outpatient staff
• (Components of plan)
• System to track influenza admissions and
  discharges has been developed as preparation for
  pandemic flu monitoring

80
Education and Training

• Infection control training is vital in our
  facility
• Modes of disease transmission prevention
• Patient care practice
• PPE
• Hand hygiene
• Use of equipment
• Handling of specimens, medical records
• Management of linens and waste
• Infection control measures outside clinical area

81
Training Plans

• 1 (components of plan)
• 2
• 3, etc.
• System to track personnel compliance
• Plans for rapid training of non-facility staff
• A
• B
• C

82
Training Is Important for Every Job

• Physicians
• House staff
• Nursing staff
• Laboratory staff
• Emergency Dept.
• Reception personnel
• Triage personnel

• Outpatient personnel
• Environmental Services
• Engineering and maintenance
• Security
• Nutrition Services

Educational materials will be language and
reading level-appropriate
83
Triage and Admission Planning

• Specific location for triage
• Use of signage to direct and instruct patients
• Physical separation of patients with flu symptoms
• Phone triage system to prioritize patients who
  need to come in for medical evaluation
• Criteria for triage will be established
• System for tracking admission and discharge of
  seasonal flu patients as prep for pandemic

84
Facility Access Plans Will Be Necessary

• Criteria and protocols for closing facility to
  new admissions
• Criteria and protocols for limiting visitors
• Security procedures for enforcement

SARS - Toronto
85
Occupational Health 1

• Delivering antiviral treatment to healthcare
  personnel who become ill
• (Components of plan)
• Detecting symptomatic personnel prior to
  reporting for duty
• (Components of plan)
• Managing personnel with symptoms of or documented
  pandemic flu
• (Duration of isolation)
• (Criteria for clearance to return to work)

86
Occupational Health 2

• Furloughing or altering work location of
  personnel at high risk for influenza
  complications
• (Policy statements)
• Housing healthcare personnel needed on-site for
  prolonged periods of time
• (Components of plan)
• Supporting personnel who have child or elder care
  responsibilities
• (Components of plan)
• Seasonal flu vaccine encouraged for all personnel

87
Surge Capacity Planning

• Threshold for canceling elective admissions and
  surgeries
• (Brief explanation)
• Facility areas for expanded bed space are
  identified
• (Details as available)
• Primary and contingency plans in place to address
  supply shortages
• (Brief explanation)

88
Surge Capacity Planning

• Minimum staffing plans/ratios being determined
• Responsibility for assessment of day-to-day
  clinical staffing needs
• (Title)__________________________
• (Other)

89
Collaboration in Regional Planning

• King County Healthcare Coalition
• Coordination across the health system
• Coordinated surge capacity strategies
• Regional Medical Resource Center
• Monitoring and distribution of human and medical
  resources
• Public Health Medical Reserve Corps
• Credentialing of volunteer personnel
• Office of the Medical Examiner
• Mass fatality management
• Supply issues

90
1918 Influenza Pandemic
Courtesy of the National Museum of Health and
Medicine, Armed Forces Institute of Pathology,
Washington, D.C
91
Resources re Pandemic Flu

• Official U.S. government website _at_
  www.pandemicflu.gov
• Centers for Disease Control Prevention _at_
  www.cdc.gov/flu/
• Washington State Dept. of Health _at_
  http//www.doh.wa.gov/panflu/
• Public Health Seattle King County _at_
  http//www.metrokc.gov/health/pandemicflu/index.ht
  m
• King County Healthcare Coalition _at_
  http//www.metrokc.gov/health/hccoalition/index.ht
  m

92
Healthcare Worker Ability and Willingness to Work
During Pandemic Flu

• Risk Perception and Attitudes
• (intended audience managers)