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H1N1 Novel Swine Influenza A Pandemic

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Authors:    David Tilton (RN, BSN) , Susan Tilton (BSB BSMT)

Purpose/Goals

The goal of the H1N1 course is to familiarize healthcare professionals with the H1N1 Novel Swine Flu virus. It focuses on the H1N1 infectious influenza strain, pandemic infection control, and pandemic preparation for the health care professional.

Objectives

Following the completion of this module, the learner will be able to:

  1. define pandemic,
  2. instruct others in the basics of social isolation during a pandemic,
  3. recognize infectious risk factors for 2009 H1N1 novel swine influenza A,
  4. discuss the importance of the World Health Organization pandemic rating scale,
  5. identify three things that they can do as an individual to prepare for a pandemic event.

Introduction

June 11, 2009 the World Health Organization announced the 2009 H1N1 Novel Swine Influenza to be a Phase-6 Pandemic, this agency’s highest alert level for an infectious disease. Up to this point the majority of those who have contracted the 2009 H1N1 virus have displayed only mild symptoms. The rapid spread of this disease across 74 countries and the potential for the virus to turn deadly on a wide scale requires a heightened level of vigilance from health professionals as they prepare for what may yet come.

Epidemic and Pandemic Influenza

The influenza virus is typically a respiratory illness with mild to debilitating symptoms whose complications when severe may lead to hospitalization or even death. Annually influenza severely affects from 3 to 5 million persons resulting in 500,000 deaths globally (Kamps, & Preiser, 2006).

New epidemic strains of the influenza virus crop up every 1 to 2 years, producing outbreaks of disease that spread more quickly and more extensively among a group of people than would normally be expected of seasonal influenza. This makes localized outbreaks of epidemic influenza a somewhat common and expected occurrence when viewed from a global perspective.

Recipe for a Pandemic?

Put simply, there are three prerequisites in order for a pandemic to emerge.

Novel: A novel pathogen emerges - one that humans have no immunity

Virulent: It infects humans causing serious illness

Contagious: It spreads easily and sustainably among humans ignoring geographic or population barriers

 

Pandemics however are uncommon events. While pandemic influenza is by its nature unpredictable, incidents with mild to moderate severity tend to occur every 10 to 40 years, with severe or devastating disease strains occurring even less frequently. The difference between an epidemic and a pandemic is that where an epidemic may spread rapidly it remains confined to a set geographic area or regional population. Pandemics, in contrast, rapidly cross geographic and population boundaries. The 2009 H1N1 Novel Swine Flu has exhibited such a spread by documented widespread community transmission occurring on at least two continents.

Recent Pandemic Influenza Events

 

Designation

Resulting Pandemic

Death Toll

1889

H3N2

Moderate

?

1918

H1N1 "Spanish"

Devastating

50-100 Million

1957

H2N2 "Asian"

Moderate

1 Million

1968

H3N2 "Hong Kong"

Mild

1 Million

2009

H1N1 "Swine"

???

???

(Kamps & Preiser, 2006, page 18)

 

Documentation regarding the characteristics of pandemics during the last 400 years has revealed that influenza pandemics tend to circumnavigate the globe in successive waves, eventually reaching everywhere, and potentially infecting every human being within the span of only a few years.

The reason that understanding the wave-like spread pattern of pandemic influenza is essential is found in history. The 1918 Spanish Flu, which had a higher death rate than the entirety of World War I, was initially highly contagious yet not particularly deadly. That is, not first time around during the spring of 1918. This pandemic flu travelled through Europe, Asia, and the Americas in a series of three distinct waves over a time period of 12 to 18 months. It was during its second wave, starting in September 1918 that the massive death tolls truly began, with the wave of primary influenza able to kill young healthy individuals within 2-days and leaving many of the survivors vulnerable to secondary bacterial pneumonias which added greatly to the suffering. For those keeping track, yes, the 2009 Novel Swine Flu is also a type of H1N1 influenza, similar in many ways to the 1918 H1N1 Spanish Flu (Kamps & Preiser, 2006).

 - N, hunh?

  • Influenza A viruses are identified from each other by key differences in external antigen subtypes; Hemagglutinin (H) and Neuraminidase (N)
  • Of Hemagglutinin (H), some 16 unique types are known while for Neuraminidase (N) 9 different forms are present
  • An influenza A visrus could therefore be known as H (from H1-to-H16), N(from N1-to-N9)
  • H1N1 is the identified external antigen subtype of the 2009 pandemic Influenza A swine-origin virus

 

The Swine in the Flu

Infectious influenza comes in a variety of strains, some of which are human specific, some that are distinct to a single species of animal, and some that can be shared across species from one animal type to certain others, or from certain animals to a human.

Antigenic Shift is the term used when a flu strain makes the jump across species. Influenza strains which can cross from an animal species and create symptoms in a human are always a concern to epidemiologists. Animals such as birds can carry a viral strain great distances very quickly as well as serving as a vast repository for an active, contagious virus. Swine can also transmit a virus amongst themselves as individuals or herds are shipped and intermingled. Due to the widespread farming of domestic pork, pigs provide a large potential reserve for a virus able to make the leap from animal to human host.

In this day of modern air travel, humans are the most efficient carrying agent of all. A couple vacationing in Sydney coming down with a respiratory spread virus can board a transoceanic flight and transport the illness to Paris and points beyond in the span of a single day. So while the origin and potential reserve of the 2009 H1N1 flu is important, the fact that it is now transmitting from human to human takes center stage.

Reassortment is a term to know when conversing about epidemic or pandemic influenza strains. To “Reassort” is the bio-genetics lingo for a virus (or more often multiple viral strains co-infecting a single host) shuffling genetic sequence and producing a “variant” viral strain or even a new “novel” virus.

Picture the genetic segments in a virus as individual cards in a deck of playing cards. Not a big deck. According to the National Institute of Allergy and Infectious Diseases (NIAID) the typical flu virus consists of eight gene packets or segments. When a virus infects a host cell be it bird, human or swine, these eight gene segment cards sort themselves out and produce copies, creating multiple genetic decks of the same identical virus. What if the cards (genetic segments) became shuffled? The genetic sequence of the reproduced virus then becomes something different from the original. It has been “reassorted”.

Reassortment of a virus may also occur when the host is infected with two different influenza viruses simultaneously, allowing two sets of the eight gene segments to intermix into a new deck of merged genetic viral material. Viral co-infection with reassortment may result in an all together new or “novel” shuffling of the viral genetic deck, producing unexpected results.

National Institute of Allergy and Infectious Diseases (http://www3.niaid.nih.gov/topics/Flu/Research/basic/AntigenicShiftIllustration.htm)

So, how do pigs fit into this picture?

Swine have the dubious pleasure of being able to “catch” certain infections from both human and avian sources. Domestic pigs also live in close proximity to both humans and domestic fowl such as chickens and ducks, especially in developing countries. An avian flu, a human flu, and the mystery of reassortment in a susceptible host (this is where the pig comes in during some scenarios) and a novel reassortment of influenza may occur. In the 2009 H1N1 novel swine influenza A pandemic, virus researchers have identified genetic segments from two swine viral strains, one human strain, and one avian strain of influenza, making the 2009 H1N1 swine flu a “quadruple reassortment” virus (Kamps & Preiser, 2006) (Thorner, 2009).

Before you start blaming the poor porkers for the 2009 H1N1 influenza pandemic, please be aware that influenza viruses containing gene segments from avian, swine, and human sources are not new. Influenza strains containing all three species (bird, pork, and people) have been documented among North American swine herds since the 1990’s. While the specifics of the origin of this current H1N1 strain have yet to be determined please remind clients that there is no risk of becoming infected with 2009 H1N1 pandemic influenza virus from eating pork or using pork products (Thorner, 2009).

Novel H1N1 Influenza?

  • Some discussion revolves around talk of the Centers for Disease Control (CDC) being urged industry to "shift" the name of the current pandemic to something less detracting of pork.
  • Simply be aware that name changes, variants and variations may occur and stay tuned to the latest FACTS...
    • 2009 H1N1 Swine Influenza, aka...
      • Novel H1N1 Influenza
      • Swine Origin Influenza
      • ...and doubtless more to come...

Characteristics of the 2009 H1N1 Novel Swine Influenza

In late March 2009 an unusual, unseasonal outbreak of respiratory illness was reported already in progress in Mexico. This outbreak was eventually identified as being related to a new strain of influenza A virus. Further cases of illness associated with the same virus began to appear in other regions of Mexico, and quickly after from other countries. On May 2, 2009 the Canadian government released a report of the identical virus, now known to be a H1N1 influenza A virus, being found in sick swine from a herd located in Alberta. Investigation revealed that the pigs had become ill following exposure to a farm worker who had recently visited Mexico and returned with flu like symptoms. With this strong indication that the infecting agent could be passed back and forth from human to swine the 2009 H1N1 Swine-Origin influenza watch began to attract public attention.

Influenza is a virus known for an annoying ability to adapt and change. In some strains of virus this occurs seasonally. With the 2009 H1N1 swine influenza it is unknown if, when, or how much it will differ at a later date from what it is currently.

Current signs and symptoms of the 2009 H1N1 Pandemic Swine Influenza include the following;

  •   Fever
  •   Cough
  •   Sore throat
  •   Malaise
  •   Headache
  •   Vomiting (often, yet not in all cases)
  •   Diarrhea (often, yet not in all cases)
  •   Chills (less common)
  •   Myalgia – muscle pain (less common)
  •   Arthralgia – joint pain (less common)

Key differences between the 2009 pandemic swine flu and seasonal influenza are being reported. Researchers in both the United States and the Netherlands note an increase in gastrointestinal distress and vomiting as compared with seasonal influenza. This increase is observed both in laboratory animal subjects and among the symptoms being reported from human cases. Among the laboratory findings is evidence that the H1N1 pandemic virus replicates more extensively in the respiratory tract than is typical of influenza A, spreading more invasively into the lungs and intestinal tract than seasonal influenza (Reinberg, 2009).

The majority of cases identified as the 2009 H1N1 novel swine influenza have experienced mild to moderate symptoms. Only two to five percent of confirmed cases in Canada and the United States have required hospitalization, as compared to around six percent in Mexico, with the most common reasons for admission being dehydration and secondary pneumonia. Among the cases in Mexico are reports of respiratory failure, acute respiratory distress syndrome, and rapidly progressing pneumonia (Thorner, 2009).

Influenza ABC's

  • Influenza A virus
    • Can infect both human and animal species
    • May rapidly spread in epidemic or pandemic fashion in animal species or humans
  • Influenza B virus
    • Human virus
    • Occasional epidemics, not associated with pandemics
  • Influenza C virus
    • Human virus associated with mild illness
    • Not associated with epidemics or pandemics

 

Transmission

Person-to-person transmission has been identified as the primary means of infection in the 2009 H1N1 pandemic influenza. Information from the World Health Organization indicates that transmissibility of this virus is substantially higher than that of seasonal influenza (Thorner, 2009).

As with all influenza A types, viral particles are present in respiratory secretions. This means that large particle droplets such as are produced by coughing or sneezing can readily convey the infection to a new host. Contact transmission from infected surfaces may also occur, and good practice around influenza A types indicates caution should be exercised when exposed to other bodily fluids such as diarrhea stool.

Viral shedding is likely to begin the day before onset of symptoms and continue until the resolution of the fever. Due to the early stage of research into the peculiarities of the 2009 H1N1 novel swine influenza individuals should be considered contagious until seven days after the illness onset. Differing periods of contagious viral shedding may be present in the immunocompromised person, those with chronic illnesses, the elderly or young infants and children. On a related note, the incubation time from viral contraction until onset of illness may range from one to seven days with the most likely timeframe being the first four days post contraction (Thorner, 2009).

Diagnosis

Recommendations differ according to regional or state authorities as to who should undergo specific testing for the 2009 H1N1 pandemic swine influenza virus. Please be aware that not all clients presenting with flu-like symptoms require testing. Some degree of professional discretion exists even where H1N1 is suspected, especially when the symptoms of illness are mild and cases have already been confirmed in that area. Be sure to check specific community or state public health guidelines.

Testing for the presence of the 2009 H1N1 virus is recommended in patients presenting with an acute febrile respiratory illness or sepsis-like syndrome. Acute febrile respiratory illness can be identified by the presence of a marked fever, 100ºF or higher, and the recent onset of at least one of the following; cough, sore throat, rhinorrhea, or nasal congestion (Thorner, 2009) (CDC, “Interim guidance for clinicians on identifying and caring for patients”, 2009).
Viral identification of the 2009 H1N1 pandemic swine influenza particle can be accomplished by either culture or real-time reverse-transcriptase PCR (the abbreviation PCR stands for polymerase chain reaction). By preference, real-time reverse-transcriptase PCR testing for influenza A, B, H1, and H3 can be conducted through state health department laboratories with the CDC confirming positive tests.

Specimens for testing consist of an upper respiratory sample; i.e., nasal swab, throat swab, nasopharyngeal swab, or nasal aspirate. Sample kits are generally available through state health departments and are preferred, as swabs with cotton tips, wooden shafts or components composed of calcium alginate are NOT ACCEPTABLE. Swabs that do meet the testing criteria (e.g. synthetic polyester or Dacron tipped with aluminum or plastic shafts), need placed in 1 to 3 mL of viral transport media. Refrigeration until testing including transportation both to the in-house laboratory and outside public health laboratory is essential.

CDC developed PCR diagnostic test kit to detect Novel H1N1 virus (http://www.cdc.gov/h1n1flu/images.htm)

Rapid antigen tests are tempting to use, yet any results obtained require interpretation with great caution. Current rapid influenza antigen tests which are commercially available distinguish between influenza A and B viruses. Unfortunately the specificity for use with the 2009 H1N1 swine influenza A virus is unknown, and poor sensitivity during testing of seasonal influenza has been demonstrated with existing rapid antigen tests. Confirmation of the 2009 H1N1 swine influenza virus can currently only be made using real-time reverse-transcriptase PCR testing, or by culture (CDC, “Use of rapid influenza diagnostic tests”, 2009).

A similar caution goes with Immunofluorescent Antibody Testing, whether direct (DFA) or indirect (IFA). Both DFA and IFA are able to distinguish between influenza A and B, however a negative DFA or IFA does not exclude the 2009 H1N1 influenza A infection as testing sensitivity to detect this virus has not yet been established (CDC, “Interim guidance on specimen collection”, 2009).

Severity of H1N1 Pandemic Swine Influenza

Dancing around the issue of risk associated with the 2009 H1N1 pandemic influenza has frequently occurred. The bottom line is this – no one knows. The “novel” H1N1 influenza virus could fade into the background of the seasonal influenza profile and never be heard of again, except by public health epidemiology trackers. On the flip side of the coin the H1N1 pandemic virus could turn into an all encompassing wave, hammering through the populations of both developed and developing countries in a fast moving and devastating contagion. Probability dictates that neither extreme will occur, that the actuality will be somewhere in the middle. We have learned a few things from previous influenza pandemics, and what we have learned we can apply to this new, novel, pandemic.

The Crisis That Wasn't

1976 - Swine flu breaks out among soldiers stationed at Fort Dix, N.J. One dies

  • Again it is an H1N1 virus, and health officials worry that they are seeing the return of the devastating 1918 H1N1 Spanish Flu pandemic
  • Fears are "confirmed" when the virus is found spreading among U.S. pig herds
  • President Gerald Ford calls for a nationawide crash vaccination program. Despite delays, a vaccine is made and a quarter of the U.S. population is inoculated
  • 25 deaths occur from a rare paralytic complication associated with the vaccination (Guillain-Barre syndrome)
  • No further deaths occurred from the 1976 H1N1 swine flu, which simply faded on, never manifesting into a pandemic...

 

Pandemics happen. Because influenza is easily transmitted within communities, and society is a fluid structure of mobile individuals, the transmission of easily spread illnesses will occur. We also know from history that the pandemic forms of influenza spread through areas, and then return to travel through the same regions again either in the same form or a slightly altered version. The 1918 Spanish Flu showed us just how deadly the second visit of a similar H1N1 virus could be.

We know that the 2009 H1N1 novel swine flu virus can spread rapidly and can cause deaths. Since awareness of this specific disease in late March of 2009, confirmed cases have been reported in 74 countries and on four continents. In Mexico, where the longest time line for this illness exists, deaths from the H1N1 swine flu have passed the hundred mark and reports continue to come in. As of June 15, 2009 reported deaths in Mexico are 108, with most related to respiratory failure and acute respiratory distress syndrome. Accompanying the respiratory failure in one quarter of the deaths are reports of renal or multi-organ failure (World Health Organization, 2009).

Due to the general pattern of behavior found in pandemic events, the World Health Organization Global Influenza Preparedness Plan defines specific phases of preparedness for organisms which have the potential to create a pandemic. Matching those phases are guidelines for suggested international and national public health actions. The current rating of the 2009 H1N1 novel swine influenza as of June 11, 2009 is that of Phase 6 (Kamps & Preiser, 2006).

WHO Global Influenza Pandemic Preparedness Plan

PERIOD

PHASE

EVENT

Inter Pandemic

Phase 1

No new virus subtypes detected.

Phase 2

Animal virus detected posing potential human risk

Phase 3

New human infection but no human-to-human spread

Pandemic Alert

Phase 4

Limited human-to-human spread in highly localized area

Phase 5

Spread to larger areas, substantial risk

Pandemic

Phase 6

Increased, sustained transmission in the general population

Post Pandemic

--

Return to Inter Pandemic Period

(Kamps & Preiser, 2006, page 112)

 

Phase 6, the “Pandemic Period” of the World Health Organization Global Pandemic Preparedness Plan acknowledges that Pandora has opened the box and that a rapidly spreading influenza virus has gained human-to-human transmission and is being identified on an international, (e.g. global), scale. The primary objective of the WHO plan becomes containment.

On a global scale this means intense monitoring and surveillance of suspected and confirmed pandemic influenza cases with supportive treatment provided to those who are already infected and targeted prophylaxis applied in areas key to containing or slowing the virus spread. Some areas have already felt the mounting institution of international containment planning as shown by infrared body temperature screening of air passengers in many international airports. This quick screening process is used to divert passengers with fever into isolation/ holding areas until they are cleared by medical authorities to continue their travels. The World Health Organization recognizes that plans may be implemented for heightened border control in some regions in an effort to contain or slow the spread of the infective agent.

On a local level, community education concerning respiratory hygiene and social distancing needs to occur, as does the preparation of available healthcare personnel, in the event that the spreading pandemic becomes even more deadly.

Infection Control Precautions

The best way to prevent infectious disease is to never be exposed. When dealing with influenza avoiding exposure is a tricky process. Infection control procedures are terrific aids inside of healthcare facilities, and the CDC has specific recommendations concerning the 2009 H1N1 novel influenza A swine origin pandemic virus;

  • Respiratory Hygiene/ Cough Etiquette infection control measures should be implemented at the first point of contact with a potentially infected person
  • Mechanisms to screen for signs and symptoms of febrile respiratory illness should be established at any point of entry to a healthcare facility

Respiratory Hygiene/Cough Etiquette

Recommended for all individuals with signs and symptoms of a respiratory infection:

  • Cover the nose/mouth when coughing or sneezing;
  • Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use;
  • If you don't have a tissue, cough or sneeze into your upper sleeve, not your hands;
  • Perform hand hygiene (e.g., hand washing with soap and water, alcohol-based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/materials.

 

The CDC also recommends that all patients presenting on admission that meet the following criteria be handled with caution (CDC, “Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A”, 2009).

  1. Clients who live, work or are present in a community where “novel” H1N1 has been identified AND who exhibit a febrile respiratory illness ~OR~
  2. Are in a community where no cases of “novel” H1N1 have been identified yet exhibit a febrile respiratory illness and has had close contact with a suspected H1N1 infectious person, or traveled within the last 7 days into a community with a confirmed H1N1 case.

CDC Interim Guidance for Infection Control for Care of Patients with
Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare setting

Patients who have confirmed, probably, or suspected case of novel H1N1 and present for care at a healthcare facility should be placed directly into individual rooms and the doors should be kept closed.

For procedures likely to generate aerosols (e.g., bronchoscopy, elective intubation, suctioning, administering nebulized medications). an airborne infection isolation room (AIIR) with negative pressure air handling of 6 to 12 air changes per house can be used.

Procedures for transport of patients in isolation precautions should be followed. Facilities should also ensure that plans are in place to communicate information about suspected cases that are transferred to other departments in the facility (e.g., radiology, laboratory) and other facilities.

The ill person should wear a surgical mask to contain secretions when outside of the patient room and should be encouraged to perform hand hygiene frequently and follow respiratory hygiene/cough etiquette practices.

 

Standard and contact infection control precautions should be continued for seven full days after the onset of the febrile respiratory symptoms in order to assure that the virus has completed its contagious shedding cycle. The CDC (2009) also encourages healthcare workers to wear fit-tested N95 respirators during the provision of routine care.

Standard N95 Disposable
 Respirator, image from CDC
(Reference link)

Surgical masks and respirators (such as the N95 type) are not the same! Surgical masks are designed to be physical barriers to incoming hazards such as large droplets or splashes. A good surgical mask also prevents outgoing contamination by trapping large particles of bodily fluids that might contain infectious organisms being expelled by the wearer. Surgical masks are not designed nor are they certified for the prevention of inhalation of small airborne contaminants. Surgical/ procedure masks are NOT designed to seal tightly against a user’s face resulting in potentially contaminated air passing through the gaps between face and mask during inhalation. Respirators however are designed to tightly fit and filter varying sizes of particles from the air. The rating, such as N95 which indicates a “filtering facepiece respirator” capable of removing 95-percent of airborne particles, designates the filtering ability of the respirator. Please be aware that in order for respirators to work properly they must be “fit tested” for the individual using them. Not all persons have the same facial characteristics, therefore one size or type of respirator will not “fit all”. Be aware that N95 respirators which are designed to catch airborne particles will eventually become “clogged” and unusable due to trapped particulate accumulation (OSHA, 2009).

Social Distancing

Social Distancing is a method of limiting exposure to the 2009 H1N1 pandemic influenza endorsed by the World Health Organization and the CDC and can work in two ways. First, by uninfected individuals who are at high risk for complications (such as persons with chronic medical problems, pregnant women, the youngest children) using measured judgment and limiting social contact that may heighten risk of exposure. This can vary from maintaining a personal space of between three to six feet from others to staying home and avoiding people altogether during times of heightened risk. Most importantly, in influenza, is the avoidance of situations involving large numbers of people in close proximity. This is particularly important in communities where cases of the 2009 H1N1 pandemic influenza have already been identified.

The use of home isolation for mildly ill patients diagnosed with or suspected of having the novel H1N1 virus could be thought of as a form of social distancing, though in a pandemic situation it is likely that all but the most severely symptomatic will be instructed to stay away from hospitals due to limited inpatient capability. If the use of home isolation is anticipated in your community, be sure to carefully instruct individuals and family members on proper hygiene precautions, and supply adequate face masks or respirators for their use.

Those with H1N1 flu who are cared for at home should:

  • Check with their health care provider about any special care they might need if they are pregnant or have a health condition such as diabetes, heart disease, asthma, or emphysema
  • Check with their health care provider about whether they should take antiviral medications
  • Stay home for 7 days after symptoms begin or until they have been symptom-free for 24 hours, whichever is longer
  • Get plenty of rest
  • Drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to keep from being dehydrated
  • Cover coughs and sneezes. Clean hands with soap and water or an alchohol-based hand rub often and especially after using tissues and after coughing or sneezing into hands
  • Avoid close contact with others - do not go to work or school while ill
  • Be watchful for warning signs that might indicate you need to seek medical attention

 

Home isolation is not for everyone. Individuals with severe symptoms or at risk for complications resulting from their symptoms are not candidates for home isolation. Those who are participating in a home isolation program should have their own room (and bathroom which can be cleaned daily with a household disinfectant) if at all possible, away from the rest of the family. One family member should be designated as the primary care giver in order to limit infectious contact with other members of the family. Even when in home isolation a face mask should be used by the ill person if available and tolerated, in order to minimize spread of the virus to others. Clear fluids should be encouraged in order to prevent dehydration as well as getting plenty of rest. Coughs and sneezes should be covered, and all parties should engage in frequent handwashing with soap and water (or use of an alcohol based hand rub).

CDC H1N1 Home Care Guidance

  • Throw tissues or other disposable items used by the sick person in the trash, wash your hands after touching used tissues or similar waste
  • Clean surfaces by wiping them with a household disinfectant according to directions on the product label
  • Linens, eating utensils and dishes used by the ill person do not need to be cleaned separately, but should not be shared without proper washing first
  • Linens should be washed using household laundry soap and tumbled dry on hot setting (avoid "hugging" the laundry prior to wash)
  • Dishes and utensils should be washed in either dishwasher or by hand with water and soap

 

Once the home isolation person is feeling better remind them of the importance of staying at home for at least 7 days, or for 24-hours AFTER all symptoms have resolved, whichever time period is LONGER. Encourage the use of the phone for those seeking social contact rather than having visitors who would be placed at risk for infection, and do remember to clean the phone, with special attention to the mouthpiece, using disinfectant before it is used by other family members. Those who are still in the home isolation time period who must go out into the community should wear a face mask and limit contact with others as much as possible.

H1N1 Home Care Emergency Indications

For Children, emergency warning signs that need urgent medical attention include:

  • Fast breathing or trouble breathing
  • Bluish or gray skin color
  • Not drinking enough fluids
  • Severe or persistent vomiting
  • Not waking up or not interacting
  • Being so irritable that the child does not want to be held
  • Flu-like symptoms improve but then return with fever and worse cough

For adults, emergency warning signs that need urgent medical attention include:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion
  • Severe or persistent vomiting
  • Flu-like symptoms improve but then return with fever and worse cough

 

Vaccination

Vaccination, when available, is a tool for use in those individuals at risk for contact with a potentially deadly viral strain, such as the 2009 H1N1 pandemic influenza. Influenza A viruses, a category into which the 2009 H1N1 novel swine flu falls, require a vaccine tailored to specific antigens to be effective. None of the recent seasonal influenza vaccines include the necessary antigens required for effect on the 2009 pandemic strain. This means that there is no effective “broad spectrum” vaccine readily available, and prior vaccination for seasonal influenza will provide no, or at most, very limited protection.

In May 2009 the CDC distributed what is referred to as “seed stocks” to vaccine manufacturers that were distinctive of the 2009 H1N1 pandemic strain. With the release of these samples work could begin in earnest on vaccine production. Best predictions indicate that it will take from six to nine months to produce an effective vaccine for the 2009 H1N1 influenza, which will put the northern hemisphere well into the seasonal influenza period. Although two manufacturers have already, as of July 1st 2009, indicated they have workable vaccine seed lines, production in any quantity will require time and financial incentive.

Prophylaxis

Prophylaxis represents an action taken in an effort to prevent a disease, or at least to stop it from spreading further. Antiviral prophylaxis guidelines related to the 2009 H1N1 novel swine influenza are available from the CDC, and are updated as new information becomes known. In general post exposure antiviral chemoprophylaxis may be considered for individuals with a high risk for complications of influenza that have been in close contact with persons confirmed or suspected to be in the infectious stage of the disease. Those under high risk of influenza complications include pregnant women, the elderly, and persons who are suffering from debilitating chronic medical conditions. Also, healthcare workers or first responders who were not using appropriate personal protective equipment during close contact with confirmed or suspected H1N1 patients during that individual’s infectious period may be candidates for antiviral prophylaxis (CDC, “Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A”, 2009).

Two antiviral medications are recommended by the CDC for post exposure prophylaxis with the 2009 H1N1 pandemic influenza virus. They are oseltamivir and zanamivir. Dosing regimens for these agents follow the schedules established for seasonal influenza exposure, and both antiviral medications must be continued for 10 days after the last known exposure to the virus occurred. The CDC is guarded on the use of antiviral agents for pre-exposure chemoprophylaxis yet recommends that should antiviral medication be used in this manner, continuation of the medication during the entire exposure period AND for 10 days after the end of exposure to the virus must occur (CDC, “Interim guidance on antiviral recommendations”, 2009).

Treatment

Treatment of the 2009 H1N1 pandemic influenza revolves around disease prevention and supportive care. Treatment of symptoms, especially dehydration and avoidance of secondary bacterial pneumonia, are essential and must occur on an individual case basis. Particular vigilance is required for the occurrence of community acquired pneumonia (CAP) in the patient rendered vulnerable by H1N1.

H1N1 Special Considerations Breastfeeding

CDC recommendations for lactating mothers suspected or diagnosed with an influenza-like illness;

  • It is okay to continue breastfeeding your infant
  • The mother should wear a face mask during breastfeeding
  • If a mask is unavailable a tissue should be used to cover the face when coughing or sneezing
  • If maternal illness prevents breastfeeding, a pump may be used for breast milk
  • Infants who are ill should continue to be breastfed

 

Complications

Complications that arise from influenza may be as deadly as the primary viral infection itself. During the 1918 Spanish Flu many of the deaths occurred from secondary bacterial pneumonia rather than the 1918 H1N1 influenza virus itself.

Groups Suspected by CDC to be at High Risk for Complications Following H1N1

  • Children less than 5 years
  • Persons greater than 65 years
  • Those less than 18 years receiving long-term aspirin therapy (increased risk of Reye syndrome)
  • Pregnant women
  • Those with chronic pulmonary, cardiac, hepatic, neurologic, neuromuscular, or metabolic disease
  • Those with immunosuppression (by either medication or HIV)
  • Residents of nursing home or other chronic care facilities

 

Secondary bacterial pneumonia is a complication associated in the past with pandemic influenza outbreaks as well as seasonal influenza. Most often secondary bacterial pneumonia is a matter of dealing with “the usual suspects” such as Streptococcus pneumoniae and Staphylococcus aureus, though other bacterial agents will take the opportunity presented by the debilitation created in the wake of the primary viral infection. Healthcare professionals need to remain observant as clients may appear initially to be recovering from the acute influenza episode. At times a lapse of two to three days occurs following the worst of the viral symptoms before temperatures again begin to rise heralding the onset of classical bacterial pneumonia symptoms such as a cough with purulent sputum. Diagnosis can be achieved by x-ray for indications of pulmonary consolidation and sputum culture.

Primary viral pneumonia can occur as a complication of any severe influenza, seasonal or pandemic. During the 1918 pandemic, primary viral influenza pneumonia with pulmonary hemorrhaging was a common finding. Clinical findings are those of an acute influenza episode that fails to spontaneously resolve and instead worsens. Chest x-rays may show the presence of diffuse interstitial infiltrates. Acute respiratory distress syndrome with marked hypoxia is often present, frequently requiring supplemental ventilator support.

Exacerbation of chronic health conditions frequently occurs in conjunction with pandemic influenza outbreaks. Existing respiratory and cardiac disease is often worsened by the bodily assault of severe influenza. COPD clients will need careful monitoring and when possible prophylactic antiviral medication should be on hand for these individuals.

Both the young and the old are vulnerable to influenza outbreaks. In children, croup secondary to influenza is often more severe than that caused by a parainfluenza virus. Failure of recovery is also a phenomenon seen during epidemic influenza outbreaks when clients, particularly the elderly, simply fail to respond to treatment and continue to deteriorate from underlying cardiac, pulmonary or multi-organ failure (Kamps & Preiser, 2006).

Care of the Healthcare Worker

Past experience with epidemic and pandemic influenza outbreaks has demonstrated a high level of need for taking proper care of the healthcare workforce. Those who provide essential care for others often fail to adequately care for themselves over the long duration in times of need. Both the CDC and WHO have recommendations for monitoring the health of workers during an infectious disease outbreak and ask health professionals to; 1) be aware of their own needs, 2) observe those they work with for signs of illness or fatigue, and 3) insist that workplaces institute processes and procedures to maintain the health of their workers.

CDC guidelines stress that in areas where the 2009 H1N1 pandemic virus is occurring healthcare personnel be monitored daily for symptoms of febrile respiratory illness. Any personnel developing these symptoms should be instructed not to report for work, or if at work should notify their supervisor and infection control personnel (CDC, “Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A”, 2009).

Acute febrile respiratory illness is defined as:

  • A measured temperature of at least 100 degrees Fahrenheit, AND
  • Recent onset of at least one of the following;
    • Rhinorrhea
    • Nasal congestion
    • Sore throat
    • Cough

 

Experience in recent years with the SARS and Avian Flu epidemics in Asia have demonstrated that healthcare workers experience high levels of stress originating from outside of the primary work environment during a contagious outbreak. Stresses may include their own fear over risk of personal illness, the real or potential illness of immediate family members, especially those who would require their direct care, the possible unavailability of daily living requirements due to societal breakdown, and even the stress surrounding the phenomena of social ostracism from other individuals fearing that the healthcare worker may be contagious. Recommendations for pandemic preparation on both an institutional and a personal level are available from various sources such as the CDC and OSHA, and the latest government information can be obtained from the website PandemicFlu.gov.

Healthcare professionals will find it difficult to focus on the care of the sick unless a measure of assurance is present that their own personal households are in order. On an institutional level absenteeism during a pandemic event must be anticipated and prepared for as employee illness, employee dependent illness, and societal reasons for being unable to be at work may occur (e.g., social distancing or home isolation, loss of home power or water, closure of grocery stores, school closures, rationing or unavailability of gas for cars or public transport). Plans for safe housing for children or dependents must be established and kept current. Essential supplies such as a two week supply of food, water, toiletries, and both prescription and non-prescription medications should be stocked and rotated on a regular basis to maintain freshness. When making preparations do not neglect to stock food and supplies for pets as well! Standard survival disaster preparation items should also be gathered and maintained such as flashlights, portable radios, batteries, a manual can opener, garbage bags, etc. Be sure to have on hand a thermometer and over the counter medicines for treating both fever and diarrhea.

Pandemic Preparation Key Points

  • Inpatient medical care may be burdened by the the surge of large numbers becoming rapidly ill
  • Medical personnel will be in short supply
  • Supplies and services may be limited
  • Travel may be difficult
  • Difficulties may linger

            (the 1918 Spanish flu hit in waves and lasted 18 months)

  • Schools, daycare facilities, public events and gatherings may be closed or canceled
  • Many businesses, banks, government offices will close
  • You or members of your family may undergo home isolation
  • Unprepared neighbors may require help or home care

Conclusion

Pandemics happen. The 2009 H1N1 novel swine origin influenza A pandemic is a fast spreading human-to-human virus that will very likely sweep through an area and then return in successive waves over a period of several years. In its first sweep through the Northern Hemisphere since its first appearance in Mexico in March 2009 it has caused mild to moderate symptoms more often than severe illness and death. Influenza viruses change however and the next sweep through may well show a dramatic increase in flu related death. Preparation for the return of the 2009 pandemic flu must occur in organized healthcare, among the general public, and especially amongst healthcare workers personal and family lives.

References

Kamps, Bernd, Hoffmann, Christian, & Preiser, Wolfgang. (2006). Influenza Report 2006. Paris: Flying Publisher.

Reinberg, Steven. (2009). Why Swine Flu Differs From Seasonal Flu. HealthDay News. Retrieved July 2, 2009, from Web site: http://www.healthfinder.gov/news/newsstory.aspx?docID=628674

Thorner, AR. (2009). Epidemiology, Clinical Manifestations, and Diagnosis of Swine H1N1 Influenza A. In: Hirsch MS (Ed.) UpToDate 17.1. Waltham, MA.

United States Centers for Disease Control and Prevention. (2009). Interim guidance for clinicians on identifying and caring for patients with swine-origin influenza A (H1N1) virus infection. Retrieved June 30, 2009, from Web site: http://www.cdc.gov/h1n1flu/identifyingpatients.htm

United States Centers for Disease Control and Prevention. (2009). Use of rapid influenza diagnostic tests for patients with influenza-like Illness during the novel H1N1 influenza virus (swine flu) outbreak: Information for health care professionals. Retrieved June 30, 2009, from Web site: http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm

United States Centers for Disease Control and Prevention. (2009). Interim guidance on specimen collection, processing, and testing for patients with suspected swine-origin influenza A (H1N1) virus infection. Retrieved May 12, 2009, from Web site: http://www.cdc.gov/h1n1flu/specimencollection.htm

United States Centers for Disease Control and Prevention. (2009). Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A (H1N1) virus infection in a healthcare setting. Retrieved May 14, 2009, from Web site: http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

United States Centers for Disease Control and Prevention. (2009). Interim guidance on antiviral recommendations for patients with novel influenza A (H1N1) virus infection and their close contact. Retrieved May 7, 2009, from Web site: http://www.cdc.gov/h1n1flu/recommendations.htm

United States Occupational Safety and Health Agency. (2009). Guidance on Preparing Workplaces for an Influenza Pandemic. Doi: OSHA 3327-05R 2009. Retrieved July 6, 2009, from Web site: http://www.osha.gov/Publications/OSHA3327pandemic.pdf

United States Department of Health and Human Services National Institutes of Allergy and Infectious Diseases. (2009). Antigenic Shift. Retrieved July 17, 2009, from web site: http://www3.niaid.nih.gov/topics/Flu/Research/basic/AntigenicShiftIllustration.htm

World Health Organization. (2009). Human infection with new influenza A (H1N1) virus: clinical observations from Mexico and other affected countries. Weekly Epidemiological Record 2009. 84(185), from Web site: http://www.who.int/wer/2009/wer8421.pdf