2009 H1N1 PANDEMIC UPDATE FOR EMS _________________________ Alexander L. Brzezny, MD, MPH

1. 2009 H1N1 PANDEMIC UPDATE FOR EMS _________________________ Alexander L. Brzezny, MD, MPH Grant County Health Officer ____________ Jackie Dawson, PhD Public Health Epidemiologist

2. TOPICS • What you may not know about influenza A • Caring for patients: suspect, probable and confirmed influenza • EMS-specific guidance /recommendations • Personal Protective Equipment (PPE) use • Triage protocols for pandemic flu surge • Vaccine and antiviral medications use • Healthcare workers & 2009-10 flu season

3. H1N1 control: Four numbers • 6 (feet of separation) • 100 (Fahrenheit) • 7 (days of exclusion) • 24 (hours w/o fever)

4. ILI=Influenza-Like Illness • Influenza-like illness (ILI): • Fever>100F (37.8C) AND • Cough AND/OR Sore Throat • Absence of other obvious known cause

5. Influenza is a Respiratory Illness • Influenza(flu) is caused by a virus that spreads easily by coughing and sneezing. • Close contact within 6 feet. • Can be transmitted by surfaces.

6. “Swine”Influenza virus .08 -.12 microns Staph aureus 1 micron

7. Social Density Residences Offices Hospitals 8 feet Elementary Schools 16 feet 12 feet 3-4 feet http://buildingsdatabook.eren.doe.gov/docs/7.4.4.xls

8. People spacing: If homes were like schools *Based on avg. 2,600 sq. ft. per single family home

9. Source: WHO

10. Swine Influenza A(H1N1)Transmission Through Species Human Virus Avian Virus Avian/Human Reassorted Virus Swine Virus Reassortment in Pigs

11. Novel H1N1 Influenza The virus contains gene segments from FOUR different influenza types: North American swine North American avian North American human Eurasian swine

14. 1.1-2 2.1-3 3+ 0.1-1 0 Rate & number (in parentheses) of hospitalized or fatal cases of PanH1 influenza by county, 2009 (n=119) Rate per 100,000: *Reported non-hospitalized PanH1 influenza case(s)

15. H1N1 SURVEILLANCE • Infectious periodfor a confirmed case of 2009 H1N1 infection: 1 day prior to the case’s illness onset to 7 days after onset (or 24 hours after fever gone). • Close contact: within about 6 feet of an ill person who is a confirmed or suspected case of 2009 H1N1 (swine flu) virus infection during the case’s infectious period

16. H1N1 SURVEILLANCE • Suspect H1N1 case: a person with an influenza-like illness (ILI) • Probable H1N1 case: a person who meets the suspect case definition and who is positive for influenza A • Confirmed H1N1 case: a person with ILI and laboratory-confirmed novel influenza A (H1N1) infection by one or more of the following tests: • Real-time RT-PCR • Viral culture

17. H1N1 SURVEILLANCE • MANDATORY REPORTING CHANGE • Healthcare workers and hospitals should IMMEDIATELY report the following patients to public health: • Hospitalized patients with laboratory-confirmed* (not “suspected”) influenza infection, • Deceased patients with laboratory-confirmed* influenza infection, and • Deceased patients suspected to have influenza infection. *a positive rapid influenza test, PCR test, direct or indirect fluorescent antibody, or viral culture

18. H1N1 SURVEILLANCE • If testing for 2009 H1N1 virus has not been performed, laboratories should submit clinical specimens or viral isolates to PHL (public health lab) within 72 H of collection from: • Deceased or critically ill patients (i.e., ICU admission) suspected to have influenza. • Hospitalized patients who have tested positive for influenza. • Option to submit specimens from non-hospitalized pregnant women who have tested positive for influenza. www.doh.wa.gov/ehsphl/Epidemiology/CD/swineflu/sflu-testalg.pdf

19. 2009 H1N1- September, 2009 Total WA 2009 H1N1 Flu Hospitalizations and DeathsPosted September 11, 2009, 1:00 PM PT Total WA Novel H1N1 Flu Hospitalizations 164 Total U.S. Novel H1N1 Flu Deaths 16

20. Novel H1N1 vs. Seasonal Influenza • Differences between the novel H1N1 and the seasonal flu variety: • It is capable of multiplying deep within the lungs. • High viral load in the upper airways. • Attack rate of 35-40% in close contacts (vs. 5%) • The immune system does not know it: lung damage more severe in those severely ill. • Most severe cases and deaths are occurring in people below 50 years of age (88%). • Projected to cause additional 30,000 - 90,000 deaths in 2009-2010.

21. Duration of hospital stay among hospitalized persons with 2009 H1N1 influenza* (Washington) *Incomplete reports on 43 cases

22. All 2009 H1N1 cases by age group & hospitalization status p<0.001

23. Symptoms of hospitalized/fatal cases of 2009 H1N1 influenza (Washington) * Number of records where presence or absence of symptom specified

24. Pre-existing conditions in hospitalized or fatal 2009 H1N1 influenza (Washington) *6 incomplete or missing case reports, 2 case investigations in progress

25. Clinical findings in hospitalized or fatal 2009 H1N1 influenza (Washington) * Number of records where presence or absence of condition specified

26. Washington 2009 H1N1 Summary • 39% of hospitalized/fatal cases reported vomiting compared to 25% of non-hospitalized cases. • 74% of hospitalized cases had a pre-existing condition compared to 22% of non-hospitalized cases. • More hospitalized cases were pregnant or had asthma, chronic lung disease, diabetes, heart disease, steroid therapy, chronic kidney disease, cancer or chemotherapy in the preceding year. • H1N1 is now endemic in Grant County and is causing regional epidemics in WA

27. Influenza high-risk individuals Pregnant women, People with asthma and other lung disease, Diabetics, Morbidly obese person, People with blood disorders (sickle cell, etc.) People with compromised immune systems, People with heart disease, stroke or similar, Those with neuromuscular diseases (CP, etc.), Hemodialysis patients (and other ESRD), Infants, elderly, nursing home residents, Individuals with a recent illness.

28. Stop the spread of 2009 Influenza viruses

29. 9/12/2009 CDC

30. Recommendations for EMS and Medical First Responder Personnel Including Firefighter and Law Enforcement First Responders • For purposes of this section, “EMS providers” means pre-hospital EMS, Law Enforcement and Fire Service First Responders.” http://www.cdc.gov/h1n1flu/guidance_ems.htm

31. Recommendations for 9-1-1 Public Safety Answering Points (PSAP) • PSAP to question callers and ascertain: • Is anyone at the incident location 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 public health.

32. Recommendations for 9-1-1 Public Safety Answering Points (PSAP) • PSAP 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 fever, cough, sore throat, shortness of breaht, nasal congestion, or other flu-like symptoms. • If the PSAP suspects ILI, they should make sure any first responders and EMS personnel are aware of the potential for “acute febrile respiratory illness” or “ILI” before the responders arrive on scene.

33. Scene Safety • Address scene safety: • If PSAP advises potential for acute febrile respiratory illness symptoms on scene, EMS personnel should don PPEPRIOR TO ENTERING SCENE • If PSAP has not identified any ILI individuals, 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 influenza. • All patients with acute febrile respiratory illness should wear a surgical mask, if tolerated by the patient.

34. Scene Safety • Assess all patients for symptoms of acute febrile respiratory illness (fever plus one or more of the following: sore throat, or cough, possibly rhinorrhea). • 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. • Report information about any ILI patients to the patient transport destination

35. Current WA State recommendations for use of PPE for HCW and EMS • EMS workers should put on a mask when attending to a patient with influenza-like illness. • When splashing or contact with respiratory fluids is likely or when close contact is expected as when caring for an infant, EMS caring for patients with influenza-like illness should use gown, gloves, and face protection (mask and goggles or faceshield). • Before and after contact with the patient, clean hands thoroughly with soap and water or an alcohol-based hand gel.

36. Current WA State recommendations for use of PPE for HCW and EMS • For cough-inducing or aerosol-generating procedures in patients with influenza-like illness, healthcare personnel should use either a respirator (e.g. N95)and eye protection (or PAPR). Such procedures include: • nebulizer treatments • trachostomy care • suctioning • bronchoscopy • intubation • post-mortem examination • While collecting respiratory specimens, an N95 respirator would be preferred but, if not available, a tightly fitting mask with eye protection is acceptable.

37. Surgical masks Easily available and commonly used for routine surgical and examination procedures High-filtration respiratory mask (i.e. N95) The masks have numbers beside them that indicate their filtration efficiency. For example, a N95 mask has 95% efficiency in filtering out particles greater than 0.3 micron under normal rate of respiration. The next generation of masks use Nano-technology which are capable of blocking particles as small as 0.027 micron. Types of Protective Masks

38. Types of Protective Masks • Small facemasks are available for children: • problematic to be worn correctly and consistently. • no facemasks (or respirators) have been cleared by the FDA for use by children. • PAPR (Powered Air Purifying Respirator)

39. Current WA State recommendations for use of PPE for HCW and EMS • Healthcare facilities should plan for allocation of personal protective equipment, including masks and N95 respirators. • Respirators should be used in accordance with Occupational Safety and Health Administration (OSHA) regulations. Staff should be checked for medical contraindications. • In addition, staff should be fit-tested and trained for respirator use (WAC 296-842, OSHA 1910.134) including proper fit-testing, use, safe removal, and disposal of respirators (www.fda.gov/cdrh/ppe/masksrespirators.html)

40. How to Reduce Respiratory Droplet Exposure? • Standard droplet respiratory precautions will significantly reduce the transmission of respiratory illness. • Consider Metered Dose Inhaler (MDI) rather than a nebulizer, supra-glottic adjunct airway devices verses intubation (Combitube or King Airways), and HEPA filters on bag-valve-mask devices or any Oxygen delivery systems (as available). • Encourage good patient compartment vehicle airflow/ventilation to reduce the concentration of aerosol accumulation when possible.

41. At The Receiving Facility • Routinely assess all persons entering a receiving facility and offer a mask to those with cough or respiratory symptoms if already not on. • Assess incoming patients in a location with negative pressure air handling if feasible. • Assure provisions for prompt isolation and assessment of symptomatic patients. • Place patients with influenza-like illness in a private room with a closed door, or cohort patients with influenza-like illnesses if private rooms are unavailable. • Have patients with influenza-like illness wear a mask when outside their hospital room, or use tissues to cover coughs and sneezes if mask use is not possible.

42. At The Receiving Facility • Place patients with suspected or confirmed 2009 H1N1 infection, especially those who require frequent aerosol-generating procedures, in an airborneinfection isolation hospital room (6-12 air changes per hour), if available. • Emphasize hand hygiene before and after patient care, after removing personal protective equipment (including gloves), and after any contact with respiratory secretions. • Limit healthcare workers entering the room of a patient in isolation to those performing direct patient care. • Healthcare workers should put on a mask when entering the room of a patient with influenza-like illness.

43. After Response /Transportation • Perform a thorough cleaning of the stretcher and all equipment that has come in contact with or been within 6 feet with an approved disinfectant, upon completion of the call. • Stretchers, railings, medical equipment control panels, adjacent flooring, walls, ceilings and work surfaces, door handles, radios, keyboards and cell phones, etc. • 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 (away from pedestrian traffic).

44. After Response /Transportation • 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 manufacturer’s 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. www.flu.gov/professional/hospital/cleaning_ems.html

45. Survival of Influenza Virus Surfaces and Affect of Humidity & Temperature* Hard non-porous surfaces 24-48 hours Plastic, stainless steel Recoverable for > 24 hours Transferable to hands up to 24 hours Cloth, paper & tissue Recoverable for 8-12 hours Transferable to hands 15 minutes Viable on hands <5 minutes only at high viral titers Potential for indirect contact transmission *Humidity 35-40%, Temperature 28C (82F) Source: Bean B, et al. JID 1982;146:47-51

46. After Response /Transportation • Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person’s infectious period should be considered for antiviral chemoprophylaxis with either oseltamivir or zanamivir. (www.cdc.gov/h1n1flu/recommendations.htm) • EMS and Healthcare Workers should be monitored daily for signs and symptoms of influenza-like illness. • Ill EMS and HCW’s should be excluded from work for 7 days, or until 24 hours after symptoms resolve, whichever is longer.

48. Effect of Prehospital and other Community Interventions #1 Pandemic outbreak: No intervention #2 Daily Cases Pandemic outbreak: With intervention #3 Days since First Case 1. Delay disease transmission and outbreak peak 2. Decompress peak burden on healthcare infrastructure 3. Diminish overall cases and health impacts

49. Summary of pre-hospital interventions • Before moving closer than 6 feet, • Use PPE for respiratory droplet precautions (a mask, fit-tested N95 respirator when appropriate, disposable gloves, gown, and eye protection). • Place a mask on the patient. • After contact with the patient clean hands thoroughly with soap and water or an alcohol-based hand gel. • After caring for the patient cleanse the vehicle for respiratory droplet contamination.

50. Sample triage forms • Employee exposure form • SORT Adolescent-Adult triage • Kaiser Permanente Colorado • CDC triage forms still preparation