Swine Flu – H1N1 Personal Protective Equipment

1. Swine Flu – H1N1 Personal Protective Equipment Infection Prevention & Control Team August 2009

2. Swine Flu & PPE Current advice on the personal protective equipment (PPE) to be worn by healthcare workers (HCW’s) when in close contact with a case of probable or confirmed swine flu is based on the following: • The swine influenza identified in the US in late April 2009, swine influenza A/H1N1 is a new swine influenza subtype and because of this current UK health and safety guidance requires the use of a higher level of bio-security than would be the case with seasonal influenza A • The identification of this new subtype in the Untied States coincided with reports of a severe unexplained respiratory illness and associated deaths affecting significant number of adults aged 25-40 years in neighbouring Mexico

3. Swine Flu & PPE Current health and safety guidance recommends that: • close contacts and HCW’s caring for a possible case of swine influenza should wear a surgical mask, plastic apron and gloves based on the likelihood of a person being a true case; • close contacts & HCW’s caring for a probable or confirmed (laboratory confirmed swine influenza) cases of swine flu should wear an FFP3 respirator, gown, gloves and eye protection in the event of performing an aerosol generating procedure • More information is available by accessing the Pandemic Influenza Infection Control Policy via the NHS Gloucestershirewebsite (type Pandemic Influenza Infection Control Policy into the search bar) or accessed on the PCT INTRANET at the web address below http://nww.glospct.nhs.uk/C0/Policies/InfectionControl/Pandemic%20Flu%20Policy.pdf

4. When to wear a surgical face mask • Wear this mask when you are entering a room with a patient with suspected or a confirmed case of swine flu • Ensure the patient wears the same type of mask and explain to them the reasons why • There is a clear consensus that masks that have become damp through use with visible strike through are no longer effective & those contaminated by patient material or are visibly soiled should be changed at once

5. How to wear a surgical face mask • To fit the mask - ensure the blue/green side is facing outwards • Secure the bottom ties around the back of your neck • Secure the top ties around the back or crown of your head • Pinch the wire at the top of the mask until it fits securely around the fleshy part of your nose • To remove the mask – unfasten/break the ties, first the bottom then the top Pull away from the face without touching the front of the mask Discard into ‘ORANGE’ clinical waste bin In a patients own home discard into non recyclable household waste

7. When to wear an FFP3 respirator mask Wear this mask only when you have a laboratory confirmed or a suspected case of swine flu WHILST carrying out an aerosol generating procedure Guidelines suggest that aerosol generating procedures include: • Intubation and related procedures: e.g. manual ventilation and suctioning • Cardiopulmonary resuscitation • Tracheostomy care and speech valve replacement • Administration of nebulised medications • Chest physiotherapy, especially chest drainage

8. Why the need for an FFP3 respirator? Several medical procedures have been reported to generate aerosols (indicated previously), and it has been suggested that some of these are associated with an increased risk of pathogen transmission. Only essential aerosol generating procedures should be carried out Only those healthcare workers who are needed to perform the procedure should be present in the immediate vicinity Preferred option is to perform these procedures in SIDE ROOMS WITH THEDOOR SHUT(or in other closed single patient areas) It is acknowledged that due to the lack of side rooms this may not always be achievable In a patients own home - recommend that any other household occupants vacate the immediate vicinity until after the procedure is complete

9. How to wear an FFP3 mask FIT TEST TRAINING MUST BE UNDERTAKEN BEFORE FFP3 MASK’S CAN BE WORN SUCCESSFULLY Only staff that have passed Fit Test training can successfully use this equipment Mask removal will depend upon mask type – Please refer to Mask Specific Fit Test training

10. Use of ‘USE BY DATE’ masks/respirators Recent work by Viscusi4 (see references) suggests that respirators stored in warehouse conditions are likely to maintain the specified filtration capacity for up to 10 years, it would therefore seem reasonable to assume that respirators past there use by date would offer some degree of protection.

11. Essential PPE • Plastic aprons to be used for all patient care • Disposable nitrile gloves to be used • Protective eye wear/splash guards can be used to protect the mucous membranes from risk of splashing - Undertake a risk assessment depending on the patient intervention *Should be worn for aerosol generating procedures* • Gowns are not required for routine care of patients with influenza but should be worn for aerosol generating procedures All of the items above are single use only and once used must be disposed of in a orange clinical waste bag In a patients own home discard all PPE into non recyclable household waste

12. Essential PPE - when to wear a gown • If extensive soiling of personal clothing or uniform with respiratory secretions is anticipated • If extensive splashing of blood, body fluids, secretions, and excretions onto skin of healthcare worker • Wear a gown for all aerosol generating procedures as previously indicated PPE guidance will be kept under review & may change during the course of the flu pandemic

13. Catch it, bin it, kill it – Patient Care Patients may also wear a surgical face mask to limit the spread Dispose of items used in patient care into ORANGE waste bins/bags In a patients own home discard into non recyclable household waste Hand wash – ‘gold standard’ Hand rub – alcohol hand rub ideal on visibly clean hands Hand wipe – Clinell hand wipe can be used on visibly soiled hands and safely by certain religious groups

14. Hand Washing Wash hands using the following 8 steps. Each step consists of five strokes rubbing backwards and forwards. 1. Wet hands under running water. Take a measure of soap. 2. Work into hands, palm to palm. 3. Right hand over back of left and vice versa. 4. Rub palm to palm, fingers interlaced. 5. Back of left fingers to right palms, fingers interlocked and vice versa. 6. Rotational rubbing of right thumb clasped in left hand and vice versa. 8. Left wrist with right hand and vice versa. 7. Rub left palm with clasped fingers of right hand and vice versa. Rinse hands under running water and dry thoroughly

16. Contact details Health Incident Control (HIC) 08454 221991 08454 221992 Via email on gpct.hic@glos.nhs.uk Infection Prevention and Control – 08454 226166 If urgent out of hours advice is needed the Consultant Microbiologists can be contacted on 08454 222222 – ask for the ‘on call microbiologist’

17. References 1. Institute of Medicine (US). Reusability of facemasks during an influenza pandemic. Washington: The Institute 2006 2. Viscusi DJ, King WP, Shaffer RE. Effect of decontamination on the filtering efficacy of two filtering face piece respirator models. J Int Soc Resp Prot, 2007; 24: 93-107 3. Phin NF, Rylands AJ, Allan J, Edwards C, Enstone J, Nguyen-Van-Tam JS. Personal protective equipment in an influenza pandemic: a UK simulation exercise. J Hosp Inf 2009 Jan;71(1):15-21 4. Viscusi DJ, Bergman M, Sinkule E, Shaffer RE. Evaluation of the filtration performance of 21 N95 filtering facepieces respirators after prolonged storage. 5. Roberge JR. The effect of surgical masks worn concurrently over N95 Filtering face piece respirators: Extended service verses increased user burden. J Int Soc Pub H Man. 2008; 14: 19-26 6. Derrick JL, Gommersal CD, Protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks Hosp Infect. 2005 Apr;59 (4):365-8. 7. Dato VM, Hostler D, Hahn ME. Simple respiratory mask [letter]. Emerg Infect Dis, 2006; 12: 1033-4. 8.http://nww.glospct.nhs.uk/C0/Policies/InfectionControl/Pandemic%20Flu%20Policy.pdf