IDSA: Pandemic and Seasonal Influenza Preparedness

 

 

# 6556

 

This morning the IDSA (Infectious Disease Society of America) and the AMA held a 2-hour webinar as part of the launch of an updated set of IDSA guidelines designed to educate federal policymakers on the issues of Pandemic and Seasonal Flu preparedness.

 

You’ll find a summary of their recommendations, and the link to download the 24-page PDF file at IDSA webpage below:

 

 

Pandemic and Seasonal Influenza

 

IDSA has published (September 2012) an updated set of Pandemic and Seasonal Influenza Principles for United States Action to educate federal policymakers about how best to prepare for and respond to seasonal and pandemic influenza.

 

IDSA's first set of principles was issued in 2007 (see previous version here).  IDSA's updated principles rely upon the experience of the 2009 H1N1 influenza pandemic and are intended to assist the U.S. Department of Health and Human Services' (HHS) Assistant Secretary for Preparedness and Response (ASPR) and other agency officials as they establish priorities for implementation of the reauthorized Pandemic and All-Hazards Preparedness Act (PAHPA).

What Action Does IDSA Recommend?

IDSA strongly believes that much work remains ahead of us, and overall responses to seasonal influenza and pandemic preparedness must be closely interrelated. The Society calls for:

• coordination between HHS and other U.S. government departments, as well as a need for better coordination within HHS, particularly concerning influenza vaccine efforts
• establishing processes for continual review of critical and rapidly evolving components of influenza preparedness, such as the contents of the Strategic National Stockpile (SNS)
• vigorously supporting the uptake of the annual influenza vaccine by health care workers including through the adoption of a mandatory approach (see IDSA's revised policy statement (PDF) for details)
• significant and sustainable multi-year funding that may be used flexibly particularly by local health departments for "All-Hazards" preparedness

 

(Continue . . . )

 

While many items were discussed during today’s webinar, the take-away message is that while much progress has been made in recent years, the United States remains vulnerable to many pandemic and other biological threats.

Influenza is by far the best known threat, but isn’t the only pandemic possibility.

 

The IDSA Guideline, in its conclusion, sums it up this way:

 

Influenza remains among the greatest infectious disease threats to our nation and the global community.  Despite the investments and progress made in research and preparedness over the past decade, substantial gaps remain. The next influenza pandemic is inevitable, only the timing,  severity,  and point of origin remain unknown.  We cannot be complacent. We cannot afford to be penny-wise and pound-foolish,  eroding the  progress made and leaving our nation and the world vulnerable.  We must be prepared.

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AHA Unveils 2010 CPR Guidelines

 

 

 

# 4989

 

 

 

Just 8 hours post-embargo, we’ve got the new American Heart Association 2010 CPR Guidelines, including the media kit with a ton of supporting information, and a terrific new video.

 

As a former AHA CPR Instructor (as not to play favorites, I was also an American Red Cross Instructor), these new guidelines are of particular interest to me.   Much has changed since I taught the class, based on research that I’ve covered in this blog in the recent past.

 

JAMA: Compression Only CPR

Results Of CPR Without Rescue Breathing

 

 

Excerpts from the press release, followed by a couple of the promotional aids, and finally the 3 minute video. 

 

 

A New Order for CPR, Spelled C-A-B

Statement Highlights:

- The 2010 AHA Guidelines for CPR and ECC update the 2005 guidelines.

- When administering CPR, immediate chest compressions should be done first.

- Untrained lay people are urged to administer Hands-Only CPR (chest compressions only).

 

DALLAS, Oct. 18 /PRNewswire-USNewswire/ -- The American Heart Association is re-arranging the ABCs of cardiopulmonary resuscitation (CPR) in its 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in Circulation: Journal of the American Heart Association.

 

Recommending that chest compressions be the first step for lay and professional rescuers to revive victims of sudden cardiac arrest, the association said the A-B-Cs (Airway-Breathing-Compressions) of CPR should now be changed to C-A-B (Compressions-Airway-Breathing).

 

<SNIP>

 

All victims in cardiac arrest need chest compressions. In the first few minutes of a cardiac arrest, victims will have oxygen remaining in their lungs and bloodstream, so starting CPR with chest compressions can pump that blood to the victim's brain and heart sooner. Research shows that rescuers who started CPR with opening the airway took 30 critical seconds longer to begin chest compressions than rescuers who began CPR with chest compressions.

 

The change in the CPR sequence applies to adults, children and infants, but excludes newborns.

 

Other recommendations, based mainly on research published since the last AHA resuscitation guidelines in 2005:

• During CPR, rescuers should give chest compressions a little faster, at a rate of at least 100 times a minute.
• Rescuers should push deeper on the chest, compressing at least two inches in adults and children and 1.5 inches in infants.
• Between each compression, rescuers should avoid leaning on the chest to allow it to return to its starting position.
• Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
• All 9-1-1 centers should assertively provide instructions over the telephone to get chest compressions started when cardiac arrest is suspected.

 

 

 

 

Given the changes in how CPR is performed, and that this is Sudden Cardiac Awareness Month (see MMWR: Sudden Cardiac Arrest Awareness Month) wouldn’t this be a good time to take (or re-take) a CPR training class?

 

It only takes a few hours, and it could end up helping you save the life of someone you love.

 

To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.

»» Read More

CDC Finalizes Flu Infection Control Guidance

 

 

# 4920

 

 

Earlier this summer the CDC published their proposed Flu Infection Control Guidance, soliciting comments and recommendations from interested parties (see CDC: Proposed Influenza Infection Control Guidance).

 

Two major concerns of HCWs (Health Care Workers) was the issue of whether flu shots should be mandatory, and a decision on what type of mask (surgical or N95 respirator) should be used for routine care of flu cases.

 

Despite calls from several major Infectious disease organizations (IDSA, SHEA, AAP), the CDC stopped short of recommending that flu shots be mandatory for HCWs.

 

Surgical masks were deemed appropriate for routine care of flu patients, although N95s are still recommended for certain higher risk procedures.

 

Rather than re-invent the wheel, I’ll simply provide you with a link to the new guidance, and refer you to Lisa Schnirring’s excellent coverage at CIDRAP.

 

 

CDC finalizes flu prevention guidance for health settings

Lisa Schnirring Staff Writer

Sep 20, 2010 (CIDRAP News) – The US Centers for Disease Control and Prevention (CDC) recently issued new guidance for preventing flu in healthcare settings that reflects a year's worth of new information about the 2009 H1N1 virus and recommends surgical masks rather than N-95 respirators when providing routine care for flu patients.

(Continue . . .)

 

 

»» Read More

FDA Farm Antibiotic Guidance Meets Resistance

 

 

# 2727

 

 

The use of antibiotics by farmers on their livestock in this country is largely unregulated, and many critics believe this policy is leading to the creation of new and dangerous antibiotic resistant bacteria.

 

The FDA recently released an updated guidance document recommending that antibiotics be used `judiciously’.   Here is how they define that:

 

FDA recommends that all antimicrobial drugs for animals and people be used only when necessary and appropriate.

 

Based on a thorough review of the available scientific information, FDA recommends that the use of medically important antimicrobial drugs in food-producing animals be limited to situations where:

 

the use of medically important antimicrobial drugs is necessary for assuring animal health; and the use of medically important antimicrobial drugs includes veterinary oversight or consultation.

 

Guidance papers do not carry the weight of law, however, and so any real changes must pass legislative muster.  According to this report from Reuters, these changes are meeting some resistance on Capitol Hill.

 

 

Officials seek limits on livestock antibiotics

WASHINGTON | Wed Jul 14, 2010 9:42pm EDT

WASHINGTON (Reuters) - Proposals to ban the use of antibiotics as a livestock growth promotant could drive up farmers costs without improving public health, skeptical lawmakers said on Wednesday.

 

Legislation to ban the decades-old practice is unlikely to pass this year, said sponsor Louise Slaughter, but her plan is to move further next year. The Food and Drug Administration recommended on June 28 that antibiotics be used only to prevent or treat livestock disease.

(Continue . . . )

 

 

The draft guidance is available from the FDA website as a 19-page PDF file :

 

The Judicious Use of Medically Important Antimicrobial Drugs in Food-Producing Animals

 

FDA invites the public to comment on the draft guidance. Submit written comments on the draft guidance to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, rm. 1061, Rockville, MD 20852. Submit electronic comments to http://www.regulations.gov.

For more information on submitting comments see the Notice of Availability.

 

 

A Q&A format information sheet is also available at the FDA site:

 

Questions and Answers on FDA's Draft Guidance on the Judicious Use of Medically Important Antimicrobial Drugs in Food-Producing Animals

 

Maryn McKenna – whose book Superbug: The Fatal Menace of MRSA deals with antibiotic resistance – did a series of blogs on her (now archived) Old Superbug website on the dangers of unregulated antibiotic usage in farm animals.

 

Several of those stories  showcased reports from the CBS Evening News with Katie Couric on the use of antibiotics on the farm.  All of these have video links:

 

CBS antibiotics and farming package, day one

CBS antibiotics and farming, day 2 - and more on the Danish experience

Antibiotics and farming — CBS follow-up video

 

If you want a not-exactly-short course on antibiotics in animals, I can think of no better resource than combing through Maryn’s Superbug archives.  

Try using the label search function to narrow down your request.  

http://www.superbugtheblog.com/search/label/animals

will return 81 mostly relevant blog entries.

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CDC: Proposed Influenza Infection Control Guidance

 

 

# 4669

 

 

The CDC has published their proposed updated guidance on influenza infection control in the Federal Registry, and will accept written public comments until July 22nd.

 

Notice: Updated Guidance: Prevention Strategies for Seasonal Influenza in Healthcare Settings

Federal Register: June 22, 2010 (Volume 75, Number 119)       Page 35497-35503

AGENCY: Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS).

ACTION: Notice with comment period.

 

While there’s a lot to absorb here, of particular interest to many HCWs (Health Care Workers) is the proposed guidance on workplace vaccinations, and the use of surgical facemasks vs. N95 respirators.

 

The issue of mandatory HCW vaccination has been both contentious and controversial.

 

New York State attempted to require vaccination as a requirement to work as a HCW, but legal challenges and vaccine shortages forced them to abandon – at least temporarily – that mandate  (see New York Rescinds Mandatory Flu Shots For HCWs).

 

• Some hospitals around the nation have adopted mandatory vaccination – or require the wearing of masks by unvaccinated workers during flu season.
• APIC (Association for Professionals in Infection Control and Epidemiology) has been promoting the idea of mandatory flu shots for HCWs for over a year (see APIC Seeking Mandatory Flu Shot For HCWs)
• And the New York State Health Department indicates that they will pursue mandatory vaccination again in 2010, assuming adequate vaccine supplies are available.

 

While strongly advocating HCW influenza vaccination, the CDC has stopped short of mandating them.

Here is the passage from the proposed guidance:

Strategies to improve HCP vaccination rates include providing incentives, providing vaccine at no cost to HCP, improving access (e.g., offering vaccination at work and during work hours), and requiring personnel to sign declination forms to acknowledge that they have been educated about the benefits and risks of vaccination.

While some have mandated influenza vaccination for all HCP who do not have a Contraindication, it should be noted that mandatory vaccination of HCP remains a controversial issue.

 

Another area of infection control that remains contentious has been the use of surgical facemasks in lieu of N95 respirators for respiratory protection.

 

For decades the assumption has been that surgical masks do not protect the wearer.  They are used to protect others from the wearer’s germs.

For that reason, N95 respirators have been routinely recommended by the CDC for HCWs in contact with pandemic flu patients.   

 

Despite that recommendation, many healthcare facilities opted to go with the (presumed) less protective surgical masks last year, citing a short supply of N95s and complaints by some HCWs that they are difficult to work in.

 

N-95 Respirator         Surgical Facemask

 

The use of surgical masks during the opening months of the pandemic led to protests by some nurses.

 

Nurses Protest Lack Of PPE’s

Report: Nurses File Complaint Over Lack Of PPE

California Nurses Association Statement On Lack Of PPE

 

Last fall we saw conflicting studies, some suggesting that surgical masks were reasonably protective against influenza.

 

JAMA: Surgical Masks vs N95 Respirators

Study: Efficacy of Facemasks Vs. Respirators

 

In guidance, updated as recently as March of this year, the CDC continued to recommend N95 respirators for HCWs who came in close contact with suspected or confirmed influenza patients.

 

This new proposed guidance relaxes those recommendations to using surgical masks for routine care, and reserving N95 masks for aerosol producing procedures (intubation, suctioning, etc).

 

Again, quoting from the proposed guidance.

HCP should don a facemask when entering the room of a patient with suspected or confirmed influenza. Remove the facemask when leaving the patient's room, dispose of the facemask in a waste container, and perform hand hygiene.

 

Based on their local needs, facilities and organizations may opt to provide employees with alternative personal protective equipment as long as it offers the same protection of the nose and mouth from splashes and sprays provided by facemasks (e.g., face shields and N95 respirators or powered air purifying respirators which would also protect against inhaling airborne particles). 

 

For aerosol producing procedures, they recommend:

 

HCP should wear respiratory protection equivalent to a fitted N95 filtering facepiece respirator (i.e., N95 respirator) or higher level of protection (e.g., powered air purifying respirator) during aerosol-generating procedures (See definition of respirator in Appendix). 

 

These proposed guidelines are obviously not going to please everyone.   

 

Those advocating stricter infection control will see the vaccination recommendations as being tepid and short of the mark, while those concerned with individual rights will view this as a victory.

 

Many hospitals will doubtless find the relaxed guidelines on respiratory protection easier to deal with (and less expensive, as well), while some HCWs will continue to question the efficacy and wisdom of using surgical masks for respiratory protection.

 

These guidelines are `living documents’, however. Always subject to change when new information – or a new pathogen – emerges.  

 

Interested parties should read the entire document, and comment if they so desire.

You may submit written comments to the following address:

Influenza Coordination Unit, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Attn: Prevention Strategies for Seasonal Influenza in Healthcare Settings, 1600 Clifton Road, NE., MS A-20, Atlanta, GA 30333.

You may also submit written comments via e-mail to: ICUpubliccomments@cdc.gov

»» Read More

Updated Interim Recommendations For Use Of Antivirals

 

 

# 4138

 

On the same day that a controversial review of the efficacy of Tamiflu appeared in the BMJ (see BMJ: A Review Of Tamiflu’s Efficacy Against Seasonal Influenza), the CDC updated their recommendations for the use of antivirals against influenza.

 

Despite the uproar raised by the Cochrane Group’s study, the truth is we’ve very little else available to treat influenza.  The only current alternative for novel H1N1 is GSK’s Relenza – which is an inhaled powder. 

 

Relenza is more difficult to administer – particularly to those with lung issues – and is in shorter supply than Tamiflu.

 

While the benefits of widespread Tamiflu use in healthy adults remain unproven - anecdotal evidence is pretty strong that in serious cases of influenza it can inhibit the replication of the virus enough to make a difference in patient outcomes.

 

Tamiflu, like any drug, can have unwanted and adverse side effects.  And like any drug, a risk-reward analysis must be made for each patient to decide if the use of the drug is justified. 

 

Here in the US, the CDC is not recommending its use in healthy adults against mild or uncomplicated influenza – although it may be `considered’. 

 

 

Here is the current decision tree.

 

 

The CDC’s recommendations are lengthy, so I’ve just reproduced the Table of Contents with Jump links. 

 

It is well worth reading completely, particularly for clinicians.

 

 

Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season

December 07, 2009 5:00 PM ET

On this Page

• Objective
• Introduction
• Treatment of confirmed or suspected influenza
• Antiviral Chemoprophylaxis of exposed individuals
• Antiviral drug use for control of influenza outbreaks in institutions
• Specific regimens for treatment and chemoprophylaxis of influenza
• Antiviral prescription and dispensing considerations
• Adverse events and contraindications
• Further information

These recommendations contain the following updates:

1. Information regarding use of intravenous peramivir under an emergency use authorization
2. Information on availability of renal dosing for peramivir
3. Updated oseltamivir dosing instructions for children younger than 1 year of age based on weight
4. Antiviral treatment and chemoprophylaxis considerations for patients vaccinated with 2009 H1N1 and seasonal influenza vaccines
5. Guidance on early empiric antiviral treatment for patients with progressive or severe influenza-like illness, regardless of underlying medical conditions
6. Guidance on early empiric antiviral treatment patients with underlying medical conditions placing them at risk for complications
7. Clarification of treatment considerations for patients with illness longer than 48 hours

These recommendations focus on the use of antiviral medications for the treatment and chemoprophylaxis of influenza.  As of December 4, 2009, influenza A (H1N1) virus (2009 H1N1), is the strain responsible for >99% of influenza in the U.S. during the 2009-2010 influenza season.  For information about other influenza viruses refer to www.cdc.gov/flu.  These recommendations were last updated on December 4, 2009, and will be updated periodically as new information becomes available.

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CDC Home Care Guidance

 

 

# 4129

 

The CDC offers, and frequently updates, guidance to health care professionals (HCPs) and to the public, on a variety of health related subjects. 

 

Below you’ll find the latest guidance to the public on home care of flu victims.

 

 

 

H1N1 Flu and Seasonal Flu

Caring for Someone Sick at Home

December 5, 2009, 6:00 AM ET

Will you know what to do if someone in your home gets the flu?

This flu season could be worse than most flu seasons with more people than usual getting sick. Hospitals and clinics may be much busier than normal. The good news is that most people with flu will be able to be cared for at home and will feel better in about a week. Learn what you can do to help your family this flu season.

Basic Facts

• About 2009 H1N1 Flu
• Flu Germs are Spread from Person to Person
• 2009 H1N1 Flu May be More Serious for Some
• Know the Symptoms of Flu
• Know the Emergency Warning Signs

Make a Sick Room

• Make a Sick Room, if You Can
• Follow the Sick Room Rules
• How to Clean the Sick Room
• Tips for Caregivers

Prevent Fluid Loss

• Tips to Prevent Fluid Loss (Dehydration)
• Check for Fluid Loss
• When to Get Medical Help for Fluid Loss

Medicine Safety

• Medicine Safety
• Medicine Safety and Children

Treat Symptoms

• Treat Fever
• Treat Dry Cough
• Treat Other Flu Symptoms

 

»» Read More

WHO Releases Interim Guidance For Mass Gathering Events

 

 

# 4004

 

With the Hajj later this month, the XXI Olympic Winter Games in Vancouver early next year, the Superbowl XLIV in January, Carnival in Rio, Mardi Gras in New Orleans and many other mass gathering events planned around the world – an influenza pandemic is a serious complicating factor.

The World Health Organization has released an 8-page guidance document entitled:

 

Interim planning considerations for mass gatherings in the context of pandemic (H1N1) 2009 influenza

Publication date: November 2009
Download the document [pdf 163kb]

In the Introduction, the authors lay out the intent of the document.

 

Introduction 

Mass gatherings are highly visible events with the potential for serious public health and political consequences  if  they are not planned and managed carefully. There  is ample documentation  that  mass  gatherings  can  amplify  and  spread  infectious  diseases.

 
Respiratory  infections,  including  influenza, have been  frequently associated with mass gatherings.  Such infections can be transmitted during the mass gathering, during transit to and from the event, and in participants’ home communities upon their return. 

Planners  of  mass  gatherings  face  special  challenges  during  a  global  influenza pandemic. The purpose of  this document  is  to outline key planning considerations for organizers of mass gatherings  in  the context of pandemic  (H1N1) 2009  influenza.  It should be used  in conjunction with WHO’s Communicable disease alert and  response for mass gatherings.

This document was prepared during September – October 2009 by WHO staff.  It was reviewed  by WHO's Virtual  Interdisciplinary Advisory Group  on Mass Gatherings.  It  is based on currently available information about pandemic (H1N1) 2009 influenza. As the pandemic  situation  evolves  and  additional  information  becomes  available,  it  may  be necessary to revise the document. Review of the document is planned in the first quarter of 2010.

 

Without speaking directly to whether any specific type of event should be cancelled or modified, they authors do recommend that a risk assessment be undertaken before an event is to proceed.

 

Risk assessment

The decision to proceed with a mass gathering or to restrict, modify, postpone, or cancel the  event  should  be  based  on  a  thorough  risk  assessment.  Event  planners  should undertake  such  an  assessment  in  partnership  with  local  and  national  public  health authorities.  The  risk  assessment  should  take  into  account  available  information  about pandemic (H1N1) 2009 influenza at global, national, and local levels. 

As part of the risk assessment, some factors may be of particular relevance such as:

• Influenza  activity:    The  level  of  pandemic  influenza  activity  circulating  in  the community  where  the  mass  gathering  is  to  be  held  should  be  considered. However, it is difficult to predict the level of activity and which strains of influenza will  be  circulating  very  far  in  advance.  WHO  provides  weekly  updates  of pandemic activity.
  
• Period of  time over which  the mass gathering will  take place:  If  the duration of the  mass  gathering  is  more  than  the  typical  incubation  period  for  pandemic (H1N1) 2009  influenza  (2-3 days),  then  the majority of event-associated cases would be expected to occur while the mass gathering is underway. In contrast, if the duration of the event is shorter, most cases would likely occur after the event as people travel and return to their home communities.
  
• Age  of  participants:  Since  younger  age  groups  appear  to  be  more  affected, mass  gathering  comprised  principally  of  children  and  young  adults  may  be associated with increased transmission compared with those comprised of older age groups.   
  
• Occurrence  of  severe  disease  and  health  care  capacity:  Although  severe disease  is uncommon,  treatment of  these patients  is challenging and  resource intensive with emergency departments and  intensive care units experiencing a disproportionate burden.    

 

The document then goes on to discuss what steps event organizers can take to reduce the transmission of the pandemic virus, or cope with influenza cases.

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WHO Releases Revised H1N1 Clinical Management Guidance

 

 

# 3991

 

 

The World Health Organization has released revised guidance on the diagnosis and treatment of the H1N1 virus.  

 

It may be downloaded from the WHO site:

 

Clinical management of human infection with new influenza A (H1N1) virus: revised guidance

Publication date: November 2009
Download the document [pdf 228kb]

 

This 15 page PDF document covers a wide range of issues.  I’ve excerpted a few sections below, but download and read the whole document.

 

Risk factors for severe disease from pandemic (H1N1) 2009 virus infection reported to date  are  considered  similar  to  those  risk  factors  identified  for  complications  from seasonal influenza.

• These include the following groups:
  •  Infants and young children, in particular <2 years
  •  Pregnant women
  •  Persons of any age with chronic pulmonary disease (e.g. asthma, COPD) 
  •  Persons of any age with chronic cardiac disease (e.g. congestive cardiac failure) 
  •  Persons with metabolic disorders (e.g. diabetes) 
  •  Persons with chronic  renal disease,  chronic hepatic disease, certain neurological conditions  (including  neuromuscular,  neurocognitive,  and  seizure  disorders), hemoglobinopathies,  or  immunosuppression,  whether  due  to  primary immunosuppressive  conditions,  such  as HIV  infection,  or  secondary  conditions, such as immunosuppressive medication or malignancy
  •  Children receiving chronic aspirin therapy 
  •  Persons aged 65 years and older

A higher  risk of  severe  complications  from pandemic  (H1N1) 2009 virus  infection has also been  reported  in  individuals who are obese  (particularly  in  those who are morbidly obese) and among disadvantaged and indigenous populations.

On average, about 1/2 of hospitalized patients have had at  least one or more underlying medical conditions1

.  However, about 1/3 of patients with very severe illness admitted to ICU were previously healthy persons. 

 

Infection control

Evidence  to date  suggests  that pandemic  (H1N1) 2009 virus  is  transmitted  similarly  to seasonal  influenza A  and  B  viruses. Appropriate  infection  control measures  (Standard plus Droplet Precautions) should be adhered  to at all  times. Whenever performing high-risk  aerosol-generating  procedures  (for  example,  bronchoscopy  or  any  procedure involving  aspiration  of  the  respiratory  tract)  use  a  particulate  respirator  (N95,  FFP2  or equivalent),  eye  protection,  gowns,  and  gloves  and  carry  out  the  procedure  in  an adequately ventilated room, either naturally or mechanically, as per WHO guidance 3

 

The duration of  isolation precautions  for hospitalized patients with  influenza  symptoms should be continued  for 7 days after onset of  illness or 24 hours after  the  resolution of fever and  respiratory symptoms, whichever  is  longer, while a patient  is  in a health-care facility.  For  prolonged  illness  with  complications  (i.e.  pneumonia),  control  measures should  be  used  during  the  duration  of  acute  illness  (i.e.  until  the  patient  has  improved clinically). Special attention is needed in caring for immunosuppressed patients who may shed  virus  for  a  longer  time  period  and  are  also  at  increased  risk  for  development  of antiviral-resistant virus

(click images to enlarge)

»» Read More

The Respirator Controversy Continues

 

 

# 3973

 

N-95 Respirator               Surgical Facemask

 

 

The N95 respirator versus surgical masks as protective gear for HCW (Health Care Workers) has been an ongoing controversy for months. 

 

Very briefly, for many years, surgical masks have been considered inferior (practically non-existent) protection for the wearer from respiratory viruses. 

 

N95 respirators have been considered the minimum `protective’ mask. 

 

Now . . .in the face of a pandemic and shortages of N95 respirators, there is a move to certify surgical masks as adequate protective gear. 

The CDC, OSHA, and the IOM have all come down in favor of N95 respirators – when that option is available – as being the preferred level of protection.  

 

But several recent studies have suggested that surgical masks may be equally protective  (see JAMA: Surgical Masks vs N95 Respirators).

 

There are practical concerns here, in that we simply don’t have enough N95 masks to go around.  But many HCWs believe that any watering down of the standards is wrong, and places their health in jeopardy.

 

ANA Calls Shortage Of N95 Respirators Unacceptable

CNA/NNOC Plan Protest Over Inadequate H1N1 Protection

Report: Nurses File Complaint Over Lack Of PPE

 

Three major Infectious Disease Organizations are now calling for a change in the standards, to make surgical masks an acceptable substitute for N95 respirators when dealing with influenza patients.  

 

While an official chance in policy on surgical masks would clear the way for hospitals to use them, it remains to be seen how well HCWs would accept that ruling. 

 

This from Medical News Today.

 

White House Urged To Modify 2009 H1N1 Guidance For Healthcare Workers And Issue Moratorium On OSHA Enforcement

Article Date: 08 Nov 2009 - 3:00 PST

 

Three leading scientific organizations specializing in infectious diseases prevention issued a letter to President Obama expressing their significant concern with current federal guidance concerning the use of personal protective equipment (PPE) by healthcare workers in treating suspected or confirmed cases of 2009 H1N1 influenza. The Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology (APIC) urged the administration to modify the guidance and issue an immediate moratorium on Occupational Safety and Health Administration's (OSHA) enforcement of the current requirements.

 
Federal PPE guidance and requirements issued recently by the Centers for Disease Control and Prevention (CDC) and OSHA include the use of fit-tested N95 respirators by healthcare workers rather than the use of standard surgical masks. According to these organizations--representing scientists, infectious disease specialists and healthcare professionals dedicated to healthcare quality, safety and infection control--this guidance does not reflect the best available scientific evidence. Their letter to the White House cited two recent studies demonstrating that the use of N95 respirators does not offer additional protection over that provided by the use of surgical masks.

(Continue . . . )

»» Read More

ACEP Guidance On Assessing The Flu

 

# 3948

 

 

During most flu seasons, the ED (Emergency Departments) of many hospitals are severely strained by the onslaught of patients with ILI (Influenza-like Illness).  

 

This year, that burden has already reached levels not normally seen until the height of flu season, and concerns are that we may see record numbers seeking help later this winter. 

 

While Emergency Departments want anyone who needs to be seen to come in for evaluation and treatment, they also need to reduce visits from the `worried well’, or those with only mild symptoms. 

Today ACEP (American College of Emergency Physicians) has released some public guidance on when it is appropriate for adults to seek medical care when stuck by a flu-like illness this winter.

 

 

HHS, ED Docs Provide H1N1 Guidelines to Public

John Commins, for HealthLeaders Media, November 4, 2009

Guidelines to help the public determine whether or not their H1N1 symptoms warrant a trip to the emergency room were released today by the American College of Emergency Physicians.

 

The guidelines are a joint effort by ACEP and the Office of the Assistant Secretary for Preparedness and Response and the Emergency Care Coordination Center, which are divisions of HHS.

 

"Emergency physicians are on the frontlines of this national emergency," said Angela Gardner, MD, president of the 28,000-member ACEP. "People are understandably concerned about contracting the H1N1 virus and confused about when to seek emergency care and when to stay home. That is why we developed a set of guidelines based on symptoms and the patient's overall state of health to help them make that decision."

(Continue. . . )

 

 

I’ve blown up, and pieced together some excerpts from the guidance to give you an idea of what it looks like.  By all means, download the entire document.

 

 

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International Travelers At Risk Of Isolation

 

# 3925

 

 

Although told in hyperbolic tabloid style, the cautionary tale below is a reminder that travelers to a number of countries should keep in mind. 

 

When you arrive in some countries, you may be screened for fever or flu-like symptoms, and if they suspect influenza you could be separated from your group and forcibly placed into isolation.

 

 

British children rounded up at airport in Egypt over swine flu fears

By Lesley Yarranton 1/11/2009

Families rounded up at the airport

Forty British children have been rounded up under draconian swine flu regulations as they arrived in to start holidays in Egypt.

 

Officials with heat-monitoring equipment are forcibly holding anyone with temperatures of more than 38C.

 

Horrified parents, taking half-term breaks, have had to watch helplessly as their tearful children are frogmarched off by armed guards to a squalid makeshift hospital at the Sharm el Sheikh resort.

 

Eight-year-old Ellie Kemp and her father, Chris, 36, of Wellingborough, Northants, were taken to a "hellhole" hospital where they had to share a bed and were fed rice and water along with at least 30 other British families. It meant they missed their week-long allinclusive holiday, for which the family paid £3,000. Mum Sarah insists Ellie had no symptoms. Sarah said: "This bloke just grabbed my daughter who was screaming. It was the most frightening experience of my life. She and her dad were stuck in a room you wouldn't leave your dog in."

 

Eleven-year-old Millie Powell, of Rochester, Kent, was also taken from her parents by force. Her worried aunt, Claire Harvey said: "Her parents were terrified Millie would catch something in the hospital."

 

A Foreign Office spokesman said: "There is little we can do as these measures have been put in place by the Egyptian authorities."

 

These measures have also been reported in India, Japan, China and other nations.   The CDC reminds US Travelers:

 

 

Possible 2009 H1N1 Flu Screening for International Travelers

Updated: October 15, 2009

Current Situation

Due to the circulation of 2009 H1N1 influenza in the United States and many other countries, airport staff in some foreign countries may check the health of arriving passengers. Many other countries, including Japan and China, are screening arriving passengers for symptoms of the flu.

 

If you are sick with symptoms of flu-like illness, you should not travel. These symptoms include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and fatigue. Some people may also have vomiting and diarrhea. People may be infected with the flu and have respiratory symptoms without a fever.

 

The United States is not screening travelers who arrive from other countries or depart for other countries.

 

In other countries that are conducting entry screening for 2009 H1N1 flu, travelers may be checked for fever and other symptoms of 2009 H1N1 flu, and their travel may be delayed. Consult the embassy of the country, or countries, in your travel itinerary for information about entry screening procedures (see Websites of U.S. Embassies, Consulates, and Diplomatic Missions for contact information).

 

When you travel internationally from the United States, officials in other countries may ask you to:

• Pass by a scanning device that checks your temperature. (The device may look like an airport metal detector, a camera, or a handheld device.) In some countries this may be done before you disembark at your destination.
• Have your temperature taken with an oral or ear thermometer
• Fill out a sheet of questions about your health
• Review information about the symptoms of 2009 H1N1 flu
• Give your address, phone number, and other contact information
• Be quarantined for a period of time if a passenger on your flight is found to have symptoms of 2009 H1N1 flu
• Contact health authorities in the country you are visiting to let them know if you become ill

If you have a fever or respiratory symptoms or are suspected to have 2009 H1N1 flu based on screening, you may be asked to:

• Be isolated from other people until you are well
• Have a medical examination
• Take a rapid flu test (which consists of a nasal swab sample)
• Be hospitalized and given medical treatment, if you test positive for 2009 H1N1 flu

Please note that the U.S. Department of State usually cannot interfere with the rights of other countries to screen airline passengers entering or exiting their countries, nor can it influence the number of days a traveler is placed in quarantine.

 

Because these outbreak-related delays, which could include several days of quarantine, may affect planned activities and lead to unexpected costs, CDC strongly recommends that travelers consider purchasing travel insurance. To find a list of possible travel health and medical evacuation insurance companies, visit Medical Information for Americans Abroad (U.S. Department of State).

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Nieman Foundation Launches Guide For Covering Pandemic Flu

 

# 3880

 

The Nieman Foundation for Journalism at Harvard today announced the launch of a web-based guide for journalists covering pandemic flu.  

 

This is a feature rich and valuable resource, and I’m looking forward to exploring it further.   I’ve placed a link to it in my side bar under Resources & Toolkits.

 

Update:  After spending less than an hour exploring this site, I’ve come away even more impressed. This is a great resource for anyone wanting to know more about pandemic influenza, not just for journalists.   

 

The contributors are a `who’s who’ of science based journalism, and they provide sorely needed context for complex issues.

Based on everything I’ve seen so far, this is highly recommended.

 

 

Excerpts from the press release are below.

 

 

Nieman Foundation Launches Guide to Covering Pandemic Flu

Cambridge, Mass. – The Nieman Foundation for Journalism at Harvard today is launching a comprehensive online guide to covering pandemic flu. Written by and for journalists, www.coveringflu.org is a one-stop resource designed to help reporters, editors, producers and other media professionals understand the complexities of the flu story. It also offers guidance and best practices for reporting on the topic.

 

Journalists using the Nieman guide can quickly access essential elements of the flu story and learn from veteran reporters and editors who have covered outbreaks such as SARS, avian influenza, and the first wave of H1N1 in spring 2009. They also can discover how to maintain their independence and continue to exercise rigorous journalistic inquiry when called on by the government and/or public health officials to share messages with the public in times of crisis.

 

As misconceptions about the flu, the H1N1 vaccine, government preparedness and other issues continue to swirl and confuse the public, careful, well researched reporting on the topic is more important than ever. And with both seasonal and H1N1 flu vaccination campaigns and other response measures coming into full swing this fall and winter, coverage that neither sensationalizes nor sugarcoats the news is crucial.

 

(Continue . . .)

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CDC Podcast: Antiviral Drug Use

 

 

# 3862

 

Although geared for clinicians, this podcast from the CDC on the use of antiviral drugs would probably be of interest to a more general audience as well. 

 

Audio, or video is available.  Runs about 7 minutes.

 

A hat tip to Indigo Girl on the Allnurses Pandemic Forum for posting this link.

 

 

 

Antiviral Drugs for the 2009-2010 Influenza Season

This podcast discusses the use of antiviral drugs for the treatment and prevention of influenza, including 2009 H1N1, during the 2009-2010 influenza season. Created: 10/19/2009 by Centers for Disease Control and Prevention (CDC). Date Released: 10/19/2009. Series Name: CDC Featured

Podcasts.

 

 

 

Running time = 7:04

 

Save This File (5MB) [right click]

To save the Podcast, right click the "Save this file" link below and select the "Save Target As..." option.

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A Gaggle Of Guidance

 

# 3857

 

 

Actually, I’m not sure what the proper collective noun is for a group of guidance documents, but no doubt, we need to come up with one. At least as  long as the CDC continues to produce volumes of informative and timely influenza guidance such as I’ve listed below.

This is What’s New on the CDC’s H1N1 site yesterday.

 

 

Mon, 19 Oct 2009 18:00:00 EST
CDC Health Alert Network (HAN) Info Service Message: Recommendations for Early Empiric Antiviral Treatment in Persons with Suspected Influenza who are at Increased Risk of Developing Severe Disease
The 2009 pandemic H1N1 influenza virus continues to be the dominant influenza virus in circulation in the U.S. The benefit of antiviral treatment is greatest when it is initiated as early as possible in the clinical course.

 

 

Mon, 19 Oct 2009 18:00:00 EST
Questions and Answers: Opening and Mixing Tamiflu Capsules with Liquids if Child Cannot Swallow Capsules
This document contains questions and answers about how to open and mix Tamiflu capsules if a child cannot swallow capsules. Tamiflu capsules may be opened and mixed with sweetened liquids, such as regular or sugar-free chocolate syrup and given that way.

 

 

Mon, 19 Oct 2009 18:00:00 EST
Flyer: Fight Flu - For First Responders
If you are part of a first response team, you already know how important your job is. Did you know you’re recommended to get 2009 H1N1 influenza (sometimes called “swine flu”) and seasonal flu vaccines?

 

 

Mon, 19 Oct 2009 18:00:00 EST
Flyer: Flu can harm you and your baby. Vaccination can Protect You Both!Spanish translation
Flu can harm you and your baby. Vaccination can Protect You Both!

 

 

Mon, 19 Oct 2009 18:00:00 EST
Flyer: Flu can harm you and your baby. Vaccination can Protect You Both!
Flu can harm you and your baby. Vaccination can Protect You Both!

 

 

Mon, 19 Oct 2009 15:30:00 EST
Translations: What Adults with HIV Infection Should Know
Translations for Arabic, French, and Russian added.

 

 

Mon, 19 Oct 2009 15:30:00 EST
Translations: What Should Pregnant Women Know
Translations for Arabic, French, and Russian added.

 

 

Mon, 19 Oct 2009 15:30:00 EST
Translations: 2009 H1N1 Flu ("Swine Flu") and You
Translations for Arabic, French, and Russian added.

 

 

Mon, 19 Oct 2009 15:25:00 EST
Podcast: Antiviral Drugs for the 2009-2010 Influenza Season
This podcast discusses the use of antiviral drugs for the treatment and prevention of influenza, including 2009 H1N1, during the 2009-2010 influenza season.

Mon, 19 Oct 2009 14:46:00 EST

 

 

H1N1 Vaccine Administration Billing Questions and Answers
Questions and answers related to billing practices for H1N1 vaccine administration, including guidance about the circumstances under which providers may bill insurance or charge patients when federal funds for H1N1 vaccination are used.

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CDC Updates Infection Control Guidance

 

 

# 3836

 

 

This afternoon the CDC released two new guidance documents for HCWs (Health Care Workers) and Health Care Facilities on infection Control measures when dealing with the H1N1 virus.

 

This guidance updates, and in some cases, reaffirms previous guidance on the H1N1 virus from the CDC.  

 

I’ve excerpted, reparagraphed, and in some cases highlighted or bolded some selections from the guidance below.

 

This is quite a large, and informative document.  Follow the link to read it in its entirety

 

Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel

October 14, 2009, 2:00 PM ET

 

 

Symptoms of Influenza and Viral Shedding

The symptoms of influenza, including 2009 H1N1 influenza, can include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, fatigue, nausea, diarrhea, and vomiting.  Depending on the case series, the proportion of persons who have laboratory confirmed 2009 H1N1 infection and do not have fever can range from about 10 to 50%.

 

Because influenza symptoms are nonspecific, it can be difficult to determine if a person has influenza based on symptoms alone. Nonetheless, decisions for clinical management, particularly for outpatients, in most cases can be made on the basis of clinical and epidemiological information. Information on diagnostic testing for 2009 H1N1 viral infection can be found at http://www.cdc.gov/h1n1flu.

 

In general, the incubation period for influenza is estimated to range from 1 to 4 days with an average of 2 days.  Influenza virus shedding (the time during which a person might be infectious to another person) begins the day before illness onset and can persist for 5 to 7 days, although some persons may shed virus for longer periods, particularly young children and severely immunocompromised persons. The amount of virus shed is greatest in the first 2-3 days of illness and appears to correlate with fever, with higher amounts of virus shed when temperatures are highest.

Modes of 2009 H1N1 Influenza Transmission

2009 H1N1 influenza virus appears to be transmitted from person to person through close contact in ways similar to other influenza viruses. Although the relative contribution of each mode is uncertain, influenza virus can potentially be transmitted through:

• Droplet exposure of mucosal surfaces (e.g., nose, mouth, and eyes) by respiratory secretions from coughing or sneezing;
• Contact, usually of hands, with an infectious patient or fomite (a surface that is contaminated with secretions) followed by self-inoculation of virus onto mucosal surfaces such as those of the nose, mouth, and eyes; and
• Small particle aerosols in the vicinity of the infectious individual.

Transmission of influenza through the air over longer distances, such as from one patient room to another, is thought not to occur. All respiratory secretions and bodily fluids, including diarrheal stools, of patients with 2009 H1N1 influenza are considered to be potentially infectious.

Respiratory Protection –

Recommendation: CDC continues to recommend the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza. This recommendation applies uniquely to the special circumstances of the current 2009 H1N1 pandemic during the fall and winter of 2009-2010 and CDC will continue to revisit its guidance as new information becomes available, within this season if necessary 

 

 

The CDC has also released a Q&A document on the highlights of this guidance, which is a bit easier to navigate.  

 

I’ve excerpted just a couple of 19 Questions & Answers provided on this page.

 

 

 

Questions and Answers about CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel

 

October 14, 2009, 4:00 PM ET

 

Q. How can healthcare facilities eliminate sources of infection and transmission within their facilities?

Healthcare facilities will want to use a multi-level approach, called the hierarchy of controls, that includes both administrative controls and engineering controls to eliminate sources of infection and prevent transmission within their facility.  Examples of these strategies are detailed in Table 1 of the guidelines.

To ensure a comprehensive infection control strategy, healthcare facilities will want to:

• Vaccinate their workforce with seasonal and 2009 H1N1 vaccines.
• Keep sick workers at home.
• Enforce respiratory hygiene and cough etiquette.
• Enhance hand hygiene compliance.
• Establish facility access control measures and triage procedures.
• Manage visitor access and movement within the facility.
• Control patient placement and transport.
• Apply isolation precautions.

Q. What personal protective equipment should be worn by healthcare personnel?

Standard precautions should be followed for all patient care.  For any activity that might generate splashes of respiratory secretions, gowns along with eye protection should be worn.  Healthcare workers who are in close contact with patients suspected or confirmed to have 2009 H1N1 influenza should wear a fit-tested, disposable N95 respirator.

 

 

 

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Updated Flu Guidance From The CDC

 

# 3808

 

The CDC continues to provide updated guidance on their website on the 2009 Pandemic, and the vaccination campaign now just getting underway.   As new information comes in, and is analyzed, the CDC continually updates these documents.

 

The What's New on the H1N1 Flu Site page keeps a running list of additions and changes to the CDC’s guidance documents.

 

New this week are a brochure and a flyer geared for parents, telling them basic information regarding seasonal and H1N1 (Swine) flu for their kids.  Download links (and a screenshot) are below.

 

 

 

 

 

Mon, 05 Oct 2009 15:54:00 EST
BROCHURE: Seasonal and 2009 H1N1 Flu: A Guide for Parents

Mon, 05 Oct 2009 15:48:00 EST
FLYER: Seasonal and 2009 H1N1 Flu: A Guide for Parents

 

(Page 1 of 2 from CDCs Guide For Parents)

 

 

Next comes an updated Q&A on Vaccines for Health Care Providers and Clinicians.

 

Mon, 05 Oct 2009 14:00:00 EST
Updated: H1N1 Clinicians Questions and Answers
The age for two doses is different for seasonal (6 months through 8 years) and 2009 H1N1 monovalent vaccine (6 months through 9 years) in the package inserts. Does CDC recommend that clinicians follow the recommendation in the package inserts?Can a person who has received LAIV test positive on a rapid influenza diagnostic test? and more...

 

Followed by a Q&A on vaccines for the general public.  Since the question is often asked about immunity acquired from having had a flu-like illness over the summer, I’ve reproduced that Q&A following the link.

 

 

Mon, 05 Oct 2009 14:00:00 EST
Updated: 2009 H1N1 Influenza Vaccine
Updated question and answer for "Should I get vaccinated against 2009 H1N1 if I have had flu-like illness since the Spring of 2009?"

Should I get vaccinated against 2009 H1N1 if I have had flu-like illness since the Spring of 2009?

The symptoms of influenza (flu-like illnesses) are similar to those caused by many other viruses. Even when influenza viruses are causing large numbers of people to get sick, other viruses are also causing illnesses. Specific testing, called “RT-PCR test,” is needed in order to tell if an illness is caused by a specific influenza strain or by some other virus. This test is different from rapid flu tests that doctors can do in their offices. Since most people with flu-like illnesses will not be tested with RT-PCR this season, the majority will not know whether they have been infected with 2009 H1N1 flu or a different virus.

 

Therefore, if you were ill but do not know if you had 2009 H1N1 infection, you should get vaccinated, if your doctor recommends it. So, most people recommended for 2009 H1N1 vaccination should be vaccinated with the 2009 H1N1 vaccine regardless of whether they had a flu-like illness earlier in the year. If you have had 2009 H1N1 flu, as confirmed by an RT-PCR test, you should have some immunity against 2009 H1N1 flu and can choose not to get the 2009 H1N1 vaccine. However, vaccination of a person with some existing immunity to the 2009 H1N1 virus will not be harmful. For more information on flu tests, see Influenza Diagnostic Testing During the 2009-2010 Flu Season.

 

Any immunity from 2009 H1N1 influenza infection or vaccination will not provide protection against seasonal influenza. All people who want protection from seasonal flu should still get their seasonal influenza vaccine.

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