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Pandemic Influenza

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Pandemic Influenza Jeanine Woltmann, RN, BS, CIC APIC-LI Meeting February 12, 2008 Avian Influenza The H5N1 strain of avian influenza (bird flu) is present in birds ... – PowerPoint PPT presentation

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Title: Pandemic Influenza


1
Pandemic Influenza
Jeanine Woltmann, RN, BS, CIC APIC-LI Meeting
February 12, 2008
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Generation of New Influenza A Virus Subtypes with
Pandemic Potential
Gerberding, J. L. et al. N Engl J Med
20043501236-1247
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Avian Influenza
  • The H5N1 strain of avian influenza (bird flu) is
    present in birds in many countries across several
    continents.
  • Bird flu is NOT the same as pandemic flu
  • Some human cases of avian influenza have also
    occurred
  • Cases occurred after close contact with infected
    birds
  • No sustained person to person transmission
  • Human death rate is high gt50
  • FDA approves US Vaccine for humans against Avian
    Influenza Virus H5N1 April 2007

10
How you get the flu?
  • Influenza transmission requires close contact
  • via exposure to large droplets (droplet
    transmission)
  • direct contact (contact transmission),
  • near-range exposure to aerosols (airborne
    transmission)
  • Typical incubation
  • 2 days
  • Range 1 - 4 days
  • Viral shedding
  • Can begin 1 day before symptom onset
  • Peak shedding first 3 days of illness
  • Subsides after 5 days in adults, can be 10 days
    in children

11
2007-08 Influenza Season
  • Feb 08 - CDC reports
  • Wide outbreaks in 11 states, including NY
  • Most Flu A (H1) causing majority- which match
    07-08 vaccine component
  • A (H3) 87 dont match 07-08 vaccine but match
    recent variant of vaccine.
  • New strain- H3N2/Brisbane-like emerged from
    Australia, too late for US vaccine
  • B 93 do not match vaccine will cause most
    illness this year?

12
2007-08 Influenza Season
  • In Feb 08, CDC reported low levels of oseltamivir
    (Tamiflu) resistance in US.
  • 3.8 of both Flu A B resistant
  • No resistance to zanamivir ( Relenza).
  • Since early in season few viruses tested for
    resistance, CDC is not recommending changes to
    use of antiviral medications

13
What is an influenza pandemic ?
  • A global influenza outbreak
  • Caused by a brand new (novel) flu virus - shift
  • Viruses can be isolated at any time of year
  • Because it is a new virus, there would be little
    or no immunity, no vaccine.
  • Disease spreads easily person to person, and
    spread across the country/world in record time.
  • Asia is the source of many outbreaks because
    birds and humans live under the same roof,
    providing opportunity for viral mixing.

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Shift - Influenza pandemics 20th Century
1918 Spanish Flu
1957 Asian Flu
1968 Hong Kong Flu
A(H1N1)
A(H2N2)
A(H3N2)
20 - 40 m deaths 675,000 US deaths
1 - 4 m deaths 70,000 US deaths
1 - 4 m deaths 34,000 US deaths
16
WHO Phases and US Stagesof a Pandemic
WHO Phases WHO Phases WHO Phases US Stages US Stages
Inter-Pandemic Period (New virus in animals, no human cases) Low risk of human cases 1 0 New domestic animal outbreak in at-risk country
Inter-Pandemic Period (New virus in animals, no human cases) Higher risk of human cases 2 0 New domestic animal outbreak in at-risk country
Pandemic Alert (New virus causes human cases) No or very limited human-human transmission 3
Pandemic Alert (New virus causes human cases) No or very limited human-human transmission 3 1 Suspected human outbreak overseas
Pandemic Alert (New virus causes human cases) Evidence of increased human-human transmission 4 2 Confirmed human outbreak overseas
Pandemic Alert (New virus causes human cases) Evidence of significant human-human transmission 5 2 Confirmed human outbreak overseas
Pandemic Period Efficient and sustained human-human transmission 6 3 Widespread human outbreaks in multiple locations overseas
Pandemic Period Efficient and sustained human-human transmission 6 4 First human case in North America
Pandemic Period Efficient and sustained human-human transmission 6 5 Spread throughout US
Pandemic Period Efficient and sustained human-human transmission 6 6 Recovery and preparation for subsequent waves
17
Opinions about Influenza
  • Pandemic avian flu is not likely.
  • Pandemic flu is certain to happen.
  • Generic vaccines are unlikely to be protective.

18
US Burden of Influenza
  • Pandemic

Moderate (1957-like) Severe (1918-like)
Illness 90 million (30) 90 million (30)
Outpatient medical care 45 million (50) 45 million (50)
Hospitalization 865,000 9, 900,000
ICU care 128,750 1,485,000
Mechanical ventilation 64,875 745,500
Deaths 209,000 1,903,000
19
If a pandemic happens What to expect
  • At the peak of a moderate pandemic influenza
    outbreak (i.e. 35 attack rate, 6 week duration),
    New York State (excluding New York City) can
    expect
  • 14,916 influenza-related hospital admissions per
    week
  • 3,728 influenza-related deaths per week
  • 2,609 deaths in the hospital
  • Influenza patients will most likely utilize
  • 63 of hospital bed capacity
  • 125 of intensive care capacity
  • 65 of hospital ventilator capacity.

20
Planning Assumptions in the US (ll)
  • The typical incubation period for influenza
    averages 2 days. 
  • Persons who become ill may transmit infection for
    one-half to one day before the onset of illness.
  • On average about 2 secondary infections will
    occur as a result of transmission from someone
    who is ill. 
  • In an affected community, a pandemic outbreak
    will last about 6 to 8 weeks. 
  • Work/school absenteeism may be as high as 40 at
    the peak.
  • At least two pandemic disease waves are likely. 

21
Pandemic impact
  • Consequences will effect all organizations
  • Extreme staffing shortages (30)
  • Overwhelming demand for services
  • (health care, first responders)
  • Limited supplies (transportation disrupted)
  • Reduced reliability in communications, power,
    water, fuel availability, transportation service
  • Reduced reliability on contractor services
  • 911 dispatch centers operating with reduced
    staff, higher call volumes
  • Large numbers of people unable to purchase food,
    pay bills high unemployment and schools closed
  • Hospitals may become high security areas

22
What is being done to prepare?
23
Public health emergency preparedness - A shared
responsibility!
  • Main Components
  • Prevention
  • Surveillance
  • Investigation
  • Alert/Notification and Communications
  • Incident Management System
  • Laboratory and Health Care Systems
  • Isolation/Quarantine
  • Mass Prophylaxis Dispensing

24
Establish and Enhance Systems to Detect and
Monitor the Pandemic
  • Provide standardized influenza reagents for
    influenza testing and research.
  • Promote development, evaluation, licensure, and
    use of point of care rapid diagnostic tests.
  • Train epidemiologists and other public health
    professionals in response and investigation
    methods.
  • Create and update protocols for investigating and
    reporting suspect and confirmed cases.
  • Ensure health care providers and the public are
    aware of case identification, reporting and
    appropriate utilization of health services.

25
Potential Strategies to Decrease the Impact of a
Pandemic
  • Prevent or delay introduction, slow spread (Buy
    time)
  • Decrease illness and death
  • Antiviral treatment and isolation for people with
    illness
  • Quarantine for those exposed
  • Social distancing
  • Vaccine when available

Weeks
26
Potential Implications of Public Health Control
Measures
  • Support needed for people who are isolated or
    quarantined
  • Limitations on travel due to restrictions,
    advisories, and screening measures
  • Limitations on public gatherings
  • Changes in the workplace to avoid disease
  • Worker absenteeism due to school closures
  • Vaccine initially limited to priority groups
  • Antivirals reserved for containment

27
Tough Issues
  • Closing all schools, movies, shows, and limiting
    subway travel (St. Louis v. Philadelphia in
    1918.).
  • Lack of adequate ventilators, ICU beds, hospital
    beds, and antiviral medications.
  • Maintaining adequate PPEs.
  • Limiting global and national travel.
  • Economic paralysis for 3-4 months.

28
VAP Ventilator Allocation PlanEstimated
17,000 vent shortage in NYS
  • Score 0 to 24 (highest)
  • lt 7 access to vent
  • gt 11 no access to vent
  • When re-assessed, if score increases may be
    taken off vent
  • Ethical Issues
  • Need hospice, palliative care
  • Grief / bereavement counseling
  • Exclusion
  • Severe Cardiac Disease
  • Malignancy
  • ESRD
  • Criteria to be based on
  • O2 Concentration
  • Bilirubin / Creatinine
  • Glasgow Coma Scale

29
Tale of Two Cities
Collins SD, Frost WH, Gover M, Sydenstricker E
Mortality from influenza and pneumonia in the 50
largest cities of the United States First Edition
Washington U.S. Government Printing Office 1930.
30
Philadelphia Liberty Loan ParadeSeptember 28,
1918
31
1918
32
Modeled Impact of Antiviral Use in Community
Mitigation
Intervention Attack rate reduction
None 42.4 --
Non-pharmaceutical interventions (NPIs) alone 11.6 73
NPIs antiviral Rx 11.0 74
NPIs antiviral Rx PEP 7.5 82
  • NPIs include case isolation, voluntary HH
    quarantine (30), closing schools, and social
    distancing
  • Antiviral Rx of 60 of cases at 24 hrs
    post-symptom onset
  • PEP (Post-exposure prophylaxis) of HH members at
    same time

N. Ferguson, Imperial College, unpublished data
33
Infection Control Measures
  • Respiratory Hygiene / cough etiquette
  • Hand Hygiene
  • Isolation Precautions
  • Personnel Protective Equipment (PPE)

34
Source control Practice respiratory
hygiene/cough etiquette
  • Promote use of masks by symptomatic persons in
    common areas (waiting rooms in physician offices
    or emergency departments) or when being
    transported (emergency vehicles).
  • Respiratory hygiene/cough etiquette is an
    effective strategy to stop the spread of germs.

35
Hand hygiene
  • Traditional hand washing
  • Soap and hot water
  • Minimum of 15 seconds
  • Alcohol based hand rubs
  • Acceptable means to disinfect/sanitize EXCEPT
    when hands are visibly soiled

36
Modes of Transmission
  • Requires close proximity via exposure to
  • large droplets (droplet transmission)
  • direct contact (contact transmission)
  • near range exposure to aerosols (suggests some
    airborne influenza transmission may occur)

37
Procedures that generate aerosols
  • Procedures
  • Endotracheal intubation
  • Aerosolized or nebulized medication
    administration
  • Diagnostic sputum induction
  • Bronchoscopy
  • Airway suctioning
  • Positive pressure ventilation via face mask (
    BiPAP and CPAP)
  • Interventions
  • Administer O2 dry
  • Change nebulized medication to administer by
    metered dose inhaler (MDI)
  • Albuterol -1st line of Rx for asthmatics
  • Peak flow monitoring to monitor patients
    response
  • Use Aerochamber to ensure proper dose and drug
    distribution

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Pandemic Flu Isolation Precautions
  • Standard Precautions and
  • Transmission based Precautions
  • Contact Precautions
  • PPE on enter room/remove prior to exit
  • Dedicated patient care equipment
  • Cohorting patients with same illness
  • Droplet Precautions
  • Goggles/eye shields
  • Place mask on patients ( if tolerated)
  • Airborne Precautions
  • Negative pressure room / Respirator mask
    (as availability permits)
  • Or private room or cohort

39
Personnel protective equipment (PPE)
  • Masks
  • Symptomatic persons
  • Contacts of ill persons
  • N95 respirators
  • Health care workers with direct patient contact
  • Gloves
  • Gown
  • Goggles and face mask



40
Donning / Doffing PPE
  • Donning sequence
  • Hand Hygiene
  • Gown
  • Respirator mask
  • Face shield / goggles
  • Gloves
  • Doffing sequence
  • Gloves
  • Face shield / Goggles
  • Respirator Mask
  • Gown
  • Hand Hygiene

41
Additional Measures
  • Avoid touching eyes, nose, mouth with
    contaminated hands ( gloved or ungloved)
  • Avoid contaminating environmental surfaces not
    related to patient care ( door knobs, light
    switches)
  • Dishes/eating utensils wear gloves when
    handling, disposable if possible or dishwasher
  • Linen directly in linen bag wear gloves/gowns
    perform hand hygiene
  • Specimens hand delivered- not sent by pneumatic
    tube

42
Treatment
  • Vaccination (when available)
  • Promote annual seasonal influenza vaccination
  • US immunization rates in HCWs 40.1 (2003)
  • In Scotland Nursing homes ? HCW influenza
    vaccination rates 5 to 51 and ? mortality 40
    among patients.
  • Antiviral Medications most effective within 48
    hrs of onset of SS
  • M2 ion channel inhibitors (amantadine /
    rimantadine) not recommended for Influenza A
    viruses due to resistance (HHS/CDC
    recommendations)
  • Neuraminidase inhibitors (zanamivir /
    oseltamivir) treatment prophylaxis of both
    Influenza A B
  • Management of Influenza complications

43
Severe MRSA Community Acquired Pneumonia
associated with Influenza (Louisiana/Georgia Dec
06-Jan 07)
  • 10 cases median age 17.5 (4mon-48yrs)
  • 6 died 60 case-fatality rate
  • S.aureus respiratory co-infections often rapidly
    progress into severe, necrotizing pneumonias (33
    flu epidemic 1968-69)
  • Usually , a complication of flu, these were
    concomitant. Infections with resistant organisms
    ? mortality

44
Triage and evaluation procedures
  • Post visual alerts (in appropriate languages) at
    the entrance to hospital outpatient facilities
    (e.g., emergency departments, outpatient clinics)
    instructing persons with respiratory symptoms
    (e.g., patients, persons who accompany them) to
    designated areas or follow certain procedures.
  • Triage for symptoms prior to registration.
  • A system for phone triage of patients for
    purposes of prioritizing patients who require a
    medical evaluation has been developed.
  • Triage patients calling for influenza symptoms
  • Discourage unnecessary visits to medical
    facilities.
  • Instruct symptomatic patients on infection
    control measures to limit transmission in the
    home and when traveling to necessary medical
    appointments.

45
Triage, evaluation, admission procedurescontinued
  • Patients with possible pandemic influenza will be
    physically separated from other patients seeking
    medical attention.
  • As the pandemic escalates locally, consider a
    separate triage area for persons presenting with
    symptoms.
  • During the peak of a pandemic, a triage officer
    may be useful for managing patient flow,
    including deferral of patients who do not require
    emergency care.

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Admission and placement of patients
  • Limit admission of ill patients to those with
    severe complications of influenza who cannot be
    cared for outside the hospital setting.
  • Admit patients to a single room or cohort
    patients. Cohorting
  • Designated units or areas of a facility for
    cohorting patients. Case cohorting should be
    based on having symptoms consistent with pandemic
    influenza.
  • Personnel assigned to cohorted patient care units
    for pandemic influenza patients should not be
    assigned to other patient care areas.
  • The number of personnel entering the cohorted
    area should be limited to those necessary for
    patient care and support.
  • Personnel assigned to cohorted patient care units
    should be educated pandemic influenza and
    measures to prevent transmission.
  • Restriction of new admissions to the affected
    unit(s).
  • May need to consider
  • Restricting all nonessential persons
  • Stopping admissions not related to pandemic
    influenza and stopping elective surgeries

48
Visitors
  • Restriction of visitors to the affected unit(s)
  • Limit visitors to persons who are necessary for
    the patients emotional well-being and care.
  • Screen visitors for signs and symptoms of
    influenza before entry into the facility and
    exclude persons who are symptomatic.
  • Family members who accompany patients with
    influenza-like illness to the hospital are
    assumed to have been exposed to influenza and
    should wear masks.
  • Instruct visitors to wear surgical mask while in
    the patients room.
  • Instruct visitors on hand-hygiene practices.
  • Give fact sheets to visitors

49
Environmental cleaning and disinfection
  • Environmental cleaning and disinfection for
    pandemic influenza follow the same general
    principles. Management of an occupied room
  • Wear gloves and wear a mask in accordance with
    droplet precautions.
  • Use any EPA-registered hospital
    detergent-disinfectant. Follow manufacturers
    recommendations for use-dilution (i.e.,
    concentration), contact time, and care in
    handling.

50
Contact tracing Rapid identification and
evaluation of all close contacts of suspect and
diagnosed cases is critical to stopping disease
transmission
  • Promptly identification, evaluation and
    monitoring of close contacts
  • Keep a register of HCW who were exposed, as well
    as, those who have recovered from pandemic
    influenza
  • Monitor absenteeism
  • Screen all HCWs for influenza-like SS prior to
    daily shift


51
Community based infection control strategies
  • Isolation and quarantine to reduce transmission
    by separating infected persons from uninfected
    persons, and exposed persons from non-exposed
    persons.
  • Social distancing
  • voluntary self-shielding
  • Cancellation of public events
  • concerts, sports events, movies, plays
  • Closure of schools, workplaces, office buildings,
    shopping malls
  • Closure of recreational facilities
  • community swimming pools, youth clubs, gymnasiums

52
Flu in Pregnant Women? Risk
  • Physical changes
  • Cardiac ?HR, stroke volume,
  • O2 consumption
  • Respiratory ? lung capacity
  • Immune changes shift cell mediated gt
  • humoral so more susceptible
  • / or affected by certain
    viruses
  • ? Hospitalizations, spontaneous abortions
  • ( 1 study gt50 did not carry to term)
  • and preterm births, adverse
    effects to
  • fetus- birth defects
  • cdc.gov/eid/content/14/1/95.htm

53
Antivirals / Pregnant Women
  • Among 61 pregnant women exposed to oseltamivir
  • Insufficient info available to assess potential
    risks to fetus with oseltamivir (tamiflu)
    zanamivir (Relenza) Most had normal outcome
    single case of trisomy 21 ancephaly
  • During clinical trials, 3 pregnancies exposed to
    tamiflu 1 spontaneous abortion , 1 termination,
    and 1 no apparent adverse outcome.

54
Non-Pharmaceutical Interventions
  • Isolation social distancing difficult in
    Pregnant Woman
  • Many either in workforce or caregivers
  • Must visit out pt prenatal care in-pt delivery
    services
  • SARS Toronto moved OB services to separate
    designated facility/ with separate air handling

55
Additional Measure-Pregnant Women
  • Suspend non-essential testing, such as routine
    sonography prenatal diagnosis
  • Limit visitors in LD to ONE
  • No visitors in post-partum
  • Instruct to stay at home quarantine for 10 days
    after D/C
  • Annual flu vaccinations recommended but
    compliance is low
  • Once Pandemic vaccine available- high priority to
    pregnant women

56
Family Preparedness Checklist
  • To plan for a pandemic
  • Store a supply of food and water
  • Have non-prescription drugs and other health
    supplies on hand
  • Start now to limit the spread of germs and
    prevent infection
  • Hand hygiene
  • Respiratory hygiene
  • Stay home if sick
  • Avoid touching eyes, nose, mouth

57
Individual and family preparedness is crucial!
  • We might have to take care of ourselves and those
    around us.
  • Gloves
  • Hand sanitizers
  • Bottled water
  • High-energy nutrition

Would you be ready?
58
Care of patients in the home
  • Management of symptomatic patients
  • Physically separate the patient with illness from
    non-ill persons living in the home.
  • Patients should not leave the home during the
    period when they are most likely to be infectious
    to others (i.e., 5 days after onset of symptoms).
  • When movement outside the home is necessary, the
    patient should follow cough etiquette and wear a
    mask.

59
Care of patients in the home
  • Management of other persons in the home
  • Persons who have not been exposed to pandemic
    influenza and who are not essential for patient
    care should not enter the home while persons are
    actively ill.
  • If unexposed persons must enter the home, they
    should avoid close contact with the patient.
  • Persons living in the home with the ill patient
    should limit contact with the patient consider
    designating one person as the primary care
    provider.
  • Household members should monitor closely for the
    development of influenza symptoms

60
Care of patients in the home
  • Infection control measures in the home
  • Hand hygiene after contact with a symptomatic
    patient or the environment in which care is
    provided.
  • Use of masks by the patient and/or caregiver
    during interactions may be of benefit.
  • Soiled dishes and eating utensils should be
    washed either in a dishwasher or by hand with
    warm water and soap. Separation of eating
    utensils for use by a patient with influenza is
    not necessary.
  • Laundry can be washed in a standard washing
    machine with warm or cold water and detergent.
    Hand hygiene should be performed after handling
    soiled laundry.
  • Tissues used by the ill patient should be placed
    in a bag and disposed with other household waste.
  • Normal cleaning of environmental surfaces and
    dishes in the home should be followed.

61
Are we prepared?
62
Questions
  • Additional Resources
  • www.nyhealth.gov
  • www.pandemicflu.gov
  • www.cdc.gov
  • www.osha.gov
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