Update on Swine Influenza - April 29, 2009

The World Health Organization (WHO) raised the pandemic alert level to Phase 5. This will help provide the impetus for all nations to boost their ability to respond effectively and prepare for a highly likely increase in the number of swine influenza cases.

Here is the latest update from the Centers for Disease Control (CDC):

The outbreak of disease in people caused by a new influenza virus of swine origin continues to grow in the United States and internationally. Today, CDC reports additional confirmed human infections, hospitalizations and the nation’s first fatality from this outbreak. The more recent illnesses and the reported death suggest that a pattern of more severe illness associated with this virus may be emerging in the U.S. Most people will not have immunity to this new virus and, as it continues to spread, more cases, more hospitalizations and more deaths are expected in the coming days and weeks.

CDC has implemented its emergency response. The agency’s goals are to reduce transmission and illness severity, and provide information to help health care providers, public health officials and the public address the challenges posed by the new virus. Yesterday, CDC issued new interim guidance for clinicians on how to care for children and pregnant women who may be infected with this virus. Young children and pregnant women are two groups of people who are at high risk of serious complications from seasonal influenza. In addition, CDC’s Division of the Strategic National Stockpile (SNS) continues to send antiviral drugs, personal protective equipment, and respiratory protection devices to all 50 states and U.S. territories to help them respond to the outbreak. The swine influenza A (H1N1) virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir. This is a rapidly evolving situation and CDC will provide updated guidance and new information as it becomes available.

For this evening's update on this blog about swine influenza, here are a few answers to questions posted by readers at Healthline:

Q: Is swine flu a new disease?
A: This particular strain of swine flu is a new disease, because it represents a new genetic combination resulting in a particular strain of the virus. However, influenza certainly originates in pigs from time to time, so swine flu as a form of influenza is not a new concept.

Q: I am a hog farmer. Can I get the virus from my swine?
A: Yes, you can. Swine influenza can be transmitted from pigs to humans. That is how it is transferred to the human race.

Q: At what stage of the illness should I seek a doctor's attention?
A. While most cases of swine influenza will hopefully turn out to be mild, and improve without any intervention, inevitably, some will be serious. Persons in high risk groups, such as young children and pregnant women, should seek medical attention, as should persons who develop symptoms such as shortness of breath, high fevers and chills, or severe weakness.

Q: I get a flu shot every year. Will this prevent me from catching the swine flu virus or any of the other flu viruses?
A: This year's flu shot is not effective against the current strain of swine flu. For the normal seasonal flu, the shot is about 75 to 90% effective. There is not yet a vaccine against this current strain of swine flu, which seems to be a naturally-occurring cross breed of the human flu, an avian flu, and 2 types of the swine flu. There is a vaccine for pigs.

Q: I'm a health care worker. Do you have any advice for me?
A: Here is some advice from the WHO intended for health care workers:

Infection prevention and control in health care in providing care for confirmed or suspected A(H1N1) swine influenza patients
Interim guidance - 29 April 2009

The current situation regarding the outbreaks of A(H1N1) swine influenza is evolving rapidly, and countries from different regions of the globe have been affected.
Based on epidemiological data, human-to-human transmission has been demonstrated along with the ability of the virus to cause community-level outbreaks which together suggest the possibility of sustained human-to-human transmission. Health care facilities now face the challenge of providing care for patients infected with A(H1N1) swine influenza. It is critical that health-care workers use appropriate infection control precautions when caring for patients with influenza-like symptoms, particularly in areas affected by outbreaks of A(H1N1) swine influenza, in order to minimize the possibility of transmission among themselves, to other health care workers, patients and visitors.

As at 29 April, human-to-human transmission of A(H1N1) swine influenza virus appears to be mainly through droplets. Therefore, the infection control precautions for patients with suspected or confirmed A(H1N1) swine influenza and those with influenza-like symptoms should prioritize the control of the spread of respiratory droplets.

Fundamentals of infection prevention strategies:

1. Administrative controls are key components, including: implementation of Standard and Droplet Precautions; avoid crowding, promote distance between patients (? 1 meter); patient triage for early detection, patient placement and reporting; organization of services; policies on rational use of available supplies; policies on patient procedures; strengthening of infection control infrastructure.

2. Environmental/engineering controls, such as basic health-care facility infrastructure, adequate ventilation, proper patient placement, and adequate environmental cleaning can help reduce the spread of some respiratory pathogens during health care.

3. Rational use of available personal protective equipment (PPE) and appropriate hand hygiene.

CRITICAL MEASURES:

1. Avoid crowding patients together, promote distance between patients
2. Protect mucosa of mouth and nose
3. Perform hand hygiene

Summary Precautions for staff providing care to patients with suspected or confirmed A(H1N1) swine influenza infection and for patients with influenza-like symptoms.

Standard and Droplet Precautions should be strengthened when working in direct contact with suspected or confirmed A(H1N1) swine influenza infected patients. Key elements:

1. Use a medical or surgical mask
2. Emphasize hand hygiene and provide hand hygiene facilities and supplies.

As per Standard Precautions, if there is a risk of splashes onto face:

1. Use face protection! Use either (1) a medical or surgical mask and eye-visor or goggles, or (2) a face shield and,

Use a gown and clean gloves.

DO NOT FORGET HAND HYGIENE AFTER PPE REMOVAL!

Aerosol generating procedures (e.g. aspiration of respiratory tract, intubation, resuscitation, bronchoscopy, autopsy) are associated with increased risk of infection transmission, and the infection control precautions should include using:

1. particulate respirator (e.g. EU FFP2, US NIOSH-certified N95);
2. eye protection (i.e. goggles);
3. a clean, non-sterile, long-sleeved gown;
4. gloves (some of these procedures require sterile gloves).

KEY ELEMENTS FOR HEALTH CARE

1. Basic infection control recommendations for all health-care facilities; Standard and Droplet Precautions when caring for a patient with an acute, febrile, respiratory illness.
2. Respiratory hygiene/cough etiquette. Health-care workers, patients and family members should cover mouth and nose with a tissue when coughing and perform hand hygiene afterwards.
3. Infection control precautions for suspected and confirmed A(H1N1) swine influenza infection: Place patient in adequately-ventilated room. If single rooms are not available, cohort patients in wards keeping at least 1 meter distance between beds. Standard, and Droplet Precautions for all persons entering the isolation room.
4. Triage, early recognition and reporting of A(H1N1) swine influenza infection. Consider A(H1N1) swine influenza infection in patients with acute, febrile, respiratory illness who have been in an affected region within the one week prior to symptom onset and who have had exposure to an A(H1N1) swine influenza infected patient or animal.
5. Standard Precautions: basic precautions designed to minimize direct unprotected exposure to potentially infected blood, body fluids or secretions.
6. Droplet Precautions: health-care workers to wear medical mask gowns and clean gloves when providing direct care.

Placement of patients with same diagnosis in designated areas may facilitate the application of infection control precautions

Additional measures to reduce nosocomial A(H1N1) swine influenza virus transmission:

1. Limit numbers of health-care workers/family members/visitors exposed to the A(H1N1) swine influenza patient.
2. Specimen collection/transport/handling within health-care facilities: Use Standard, and Droplet Precautions for specimen collection. Use Standard
Precautions for specimen transport to the laboratory. Health-care facility laboratories should follow good bio-safety practices.

Family member/visitor recommendations

Family members/visitors should be limited to those essential for patient support and should use the same infection control precautions as health-care workers.

Patient transport within health-care facilities: Suspect or confirmed A(H1N1) swine influenza patients should wear a medical/surgical mask.

Pre-hospital care

Infection control precautions are similar to those practiced during hospital care for all involved in the care of suspected A(H1N1) swine influenza patients. (e.g. transportation to hospital).

Occupational health

Monitor health of health-care workers exposed to A(H1N1) swine influenza patients. Antiviral prophylaxis should follow local policy. Health-care workers with symptoms should stay at home.

Waste disposal

Treat any waste that could be contaminated with A(H1N1) swine influenza virus as infectious clinical waste, e.g. used masks.


Dishes/eating utensils

Wash using routine procedures with water and detergent. Use non-sterile rubber gloves.

Linen and laundry

Wash with routine procedures, water and detergent; avoid shaking linen/laundry during handling before washing. Use non-sterile rubber gloves.

Environmental cleaning and disinfection

Clean soiled and/or frequently touched surfaces regularly with a disinfectant. e.g. door handles.

Patient care equipment

Dedicate separate equipment to A(H1N1) swine influenza patients. If not possible, clean and disinfect before reuse in another patient.


Q: Has swine flu been fatal to anyone diagnosed yet? Can it be? if so, what are the chances of it being fatal?
A: Yes, it has been fatal, both in the U.S. (one case as of today) and abroad (many reported fatal cases in Mexico). There are no statistics to support "the odds" of fatality. So far, swine flu appears to be much more mild than the dreaded avian flu.

Q: Why is the swine flu receiving all this publicity when more than 36,000 people per year die from the "regular" flu?
A: The cause for concern is that this is a new, and as yet unpredictable disease, for which there is no "herd immunity." We do not yet know if the viral syndrome will worsen, stay the same, or improve with human to human transmission, and there is not yet a vaccine against this strain of influenza. It is always better to err of the side of caution. We don't know how quickly it will spread, or how many persons will ultimately be infected.

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