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Novel H1N1 Influenza Pandemic Flu Primer FAQ's

What is 2009 Novel H1N1 (Swine) Influenza?
Swine Flu or more properly, Novel H1N1 influenza, is a respiratory disease caused by type A influenza viruses. The infection was originally called "swine" flu because it originated from pigs in Mexico, emerging from its animal host to infect humans. In fact humans, pigs and birds share Flu viruses all the time, and the genes of these viruses are modified each time they are transmitted from animals to humans and vice versa.
What is an Influenza Pandemic?
A Pandemic is an infection that occurs on a global scale. An Influenza Pandemic occurs when a new ("novel") Influenza virus with human, swine and avian genes that has never circulated among humans before emerges from an animal reservoir to cause sustained human-to-human transmission on a global scale. This is fortunately an uncommon event, but on the rare occasion that this type of transmission with a new virus does happen, a pandemic results.
How is Influenza Virus transmitted?
Flu viruses are spread mainly from person to person through coughing or sneezing by people with influenza. Transmission via large-particle droplets requires close contact between source and recipient persons because droplets do not remain suspended in the air and generally travel only a short distance (> 6 feet). Sometimes people may become infected by touching something - such as a surface or object - with flu viruses on it and then touching their mouth or nose. The latest information available indicates that Novel H1N1 (Swine) Flu is spread very similarly to Seasonal Flu viruses.
What is the incubation period for Influenza?
The incubation period for Seasonal and Novel H1N1Influenza infection is from 1-5 days from the time of contact to onset of symptoms.
What are the signs and symptoms of Influenza?
The symptoms of Novel H1N1 flu in people are similar to the symptoms of regular human flu, except that patients with Novel H1N1 Flu may also have GI symptoms. They include fever, cough, sore throat, body aches, headache, chills, fatigue, and with Novel H1N1 influenza, diarrhea and vomiting in about 25% of people sick with the virus.
What is meant by Influenza-Like Illness (ILI)?
The CDC advises all healthcare workers with direct patient contact to become familiar with the signs and symptoms of "Influenza-Like Illness" or "ILI" for short. ILI is defined by the CDC as:
  • Temperature ≥ 100.0 F
  • Cough
  • Sore throat
In the absence of a known cause other than influenza

Additional symptoms associated with seasonal and Novel H1N1 Influenza that should be assessed in patients presenting with ILI:
  • Fatigue, body aches, chills, congested/runny nose, headache
  • 24% of patients with H1N1 Flu will also have vomiting and/or diarrhea
What is the duration of symptoms of Influenza?
The worst symptoms from the Flu last 3-5 days, but some patients will experience Flu symptoms for 7-10 days or longer, depending on age, immune status and complications such as secondary bacterial infection.
How long does an infected person shed the influenza virus?
According to the CDC, "people infected with seasonal and novel H1N1 flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days after. This can be longer in some people, especially children and people with weakened immune systems and in people infected with the new H1N1 virus". The latest evidence in patients with Novel H1N1 influenza is that persistence of cough may be an indicator of ongoing virus shedding. Further studies are being completed to address this issue.
How long can the Influenza virus survive on environmental surfaces?
The CDC quotes studies showing that Influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on the surface. This makes surface decontamination in the environment of someone sick with the Flu an important component in the prevention of spread of the Flu virus.
What can I do to prevent from becoming ill with Influenza virus?
The CDC recommends several basic behaviors in order to prevent becoming ill with the Flu and spreading it to your co-workers, patients, or your own family members:
  • Cover your nose and mouth with a facial tissue when you cough or sneeze. Throw the tissue in the trash after you use it. If tissues are not available, cough or sneeze into the bend of your elbow, not into your hands.
  • Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand sanitizers are effective against the influenza virus and have the advantage of being available as portable, personal-sized dispensers that can be carried with you wherever you go.
  • Avoid touching your eyes, nose or mouth. Germs spread this way.
  • Try to avoid close contact with sick people.
  • If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.) Keep away from others as much as possible to keep from making others sick. Note: if you are a healthcare worker who gets sick with the Flu, you must stay home from work for 7 days or until symptoms have resolved, whichever is longer.
  • Get vaccinated for both seasonal and Novel H1N1 Influenza
What should I do if I get sick with the Flu?
If you are sick, you should stay home and avoid contact with other people as much as possible to keep from spreading your illness to others. Get lots of rest, drink plenty of fluids to prevent dehydration and use acetaminophen or ibuprofen to control fever, aches and pains. If you are a healthcare worker with direct patient contact, and/or you are in a high risk group for complications from either Seasonal or Novel H1N1 Influenza, you should be tested and treated (see below).
Who is at greatest risk for serious or life-threatening disease from Seasonal Influenza?
Children younger than 5 years old, adults 65 years of age and older, Residents of nursing homes and other chronic-care facilities, and persons with the following conditions: Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus); Immunosuppression, including that caused by medications or by HIV; Pregnant women; Persons younger than 19 years of age who are receiving long-term aspirin therapy.
Who is at greatest risk for serious or life-threatening disease from Novel H1N1 Influenza?
Pregnant women, household contacts and caregivers for children younger than 6 months of age, healthcare and emergency medical services personnel, all people from 6 months through 24 years of age, and persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
What have we learned about Novel H1N1 Influenza infection from this winter in the southern hemisphere?
After mid-July (mid-January for us) disease activity in most parts of the country decreased; the Novel H1N1 virus has not changed, or mutated, significantly so far; the most at-risk patients in the Southern Hemisphere are similar to those seen in the US (as discussed above); healthcare systems experienced stress, but it was generally geographically isolated and relatively short-lived; commonly-used community mitigation measures included: school closures, cancellation of mass gatherings, isolation and quarantine, other social distancing measures, border screening and temporary flight cancellations; all countries experienced some time-limited and/or geographically-isolated socioeconomic effects, including decreased tourism.
Who should receive Seasonal Influenza vaccination?
The CDC recommends that the following individuals receive annual vaccination:
  • Children aged 6 months up to their 19th birthday
  • Pregnant women
  • People 50 years of age and older
  • People of any age with certain chronic medical conditions
  • People who live in nursing homes and other long-term care facilities
  • People who live with or care for those at high risk for complications from flu, including:
    • Health care workers
    • Household contacts of persons at high risk for complications from the flu
    • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)
Who should receive the Novel H1N1 vaccine?
The CDC is anticipating limited early supplies of this vaccine, so priority will be given to:
  • pregnant women
  • people who live with or care for children younger than 6 months of age
  • health care and emergency medical services personnel with direct patient contact
  • children 6 months through 4 years of age
  • children 5 through 18 years of age who have chronic medical conditions
What patients presenting with influenza-like illness should be tested for influenza virus infection?
The Centers for Disease Control and Prevention (CDC) recommends that priority for laboratory testing for influenza be given to persons who 1) require hospitalization or 2) are at high-risk for severe disease from seasonal influenza, even if infection with Novel H1N1 influenza is suspected since there is considerable overlap between high risk patient categories for each virus.
Why is UK Healthcare recommending that healthcare workers who develop influenza-like illness also be tested for influenza?
Although CDC does not list healthcare workers (HCW) in their recommendations for who should be tested and treated, it was felt that in order to protect our workforce from unnecessary absence from work, all HCW's with an ILI should be offered testing to distinguish whether they have influenza, in which case they would have to be away from work for at least 7 days, or another respiratory viral infection, in which case they could return to work once they are feeling better and are able to work. This addition to the CDC recommendations will become critical if we experience the anticipated 30-40% workforce shortage during the peak of the pandemic.
What influenza test should be sent on hospitalized patients, high risk patients, and healthcare workers?
The recommended test is an Influenza reverse-transcriptase polymerase chain reaction (RT-PCR) test.
What is the appropriate patient sample to send for RT-PCR?
A nasopharyngeal swab should be obtained from the patient by a healthcare worker wearing an N95 particulate mask, eye protection, and protective gown and gloves using the new Becton Dickinson 3ML FLOCK FLEX MINITIP swab. The swab is inserted through the nostril and advanced to the nasopharynx of the patient. Once the specimen has been obtained, the swab is removed, the shaft broken at the red-marked score line, and the portion of the swab containing the tip is placed into the accompanying viral transport media. This is then labeled, bagged and sent to the clinical microbiology laboratory.
How long does it take to obtain results of RT-PCR testing?
Depending upon when a specimen is received for testing, results will be available within 4 to 24 hours of testing for most patients.
What information will the RT-PCR test give me?
RT-PCR is used to detect viral RNA in clinical samples. The test can determine whether a patient's nasopharyngeal secretions contain an Influenza A, Influenza B virus and/or Respiratory Syncytial Virus (RSV). Further testing is performed by the lab on samples testing positive for Influenza A to distinguish what Influenza subtype (Novel H1N1, Seasonal H1N1, H3N2) the patient's sample contains. Influenza subtype determination is important because antiviral susceptibility varies among Influenza viruses.
What patients presenting with influenza-like illness should be treated with an antiviral medication for influenza virus infection?
The CDC recommends that priority for treatment of suspected or documented influenza infection be given to persons who 1.) require hospitalization and 2.) are at high-risk for severe disease from Influenza (whether hospitalized or managed as outpatients).
Why is UK Healthcare recommending that healthcare workers who either have unprotected close contact with a person with influenza or who develop influenza-like illness themselves also be treated for influenza?
We are making this recommendation in the case of actual infection in order to shorten the duration of the healthcare worker's clinical illness, decrease viral shedding, and reduce the risk of complications from influenza. Treatment of healthcare workers would potentially speed recovery from the Flu and minimize complications that may keep them from rejoining a strained, reduced workforce in as short a time as possible (7 days minimum per recommendations from CDC). In the case of unprotected exposure, we recommend antiviral chemoprophylaxis in order to prevent the exposed healthcare worker from becoming ill with Influenza, thereby preventing missed work and the potential to infect patients as well as family members in contact with the healthcare worker.
Who else should be considered for antiviral chemoprophylaxis?
In addition to healthcare workers, the CDC also recommends that high risk individuals with close contact exposure to someone with influenza be considered for antiviral chemoprophylaxis.
What, exactly, is meant by "close contact" exposure?
The CDC defines close contact as having cared for or lived with a person who is a confirmed, probable, or suspected case of influenza, or having been in a setting where there was a high likelihood of contact with respiratory droplets and/or body fluids of such a person. The distance from infected to susceptible individuals that is usually used as a guide as to what is meant by "close" contact is 6 feet, but the duration of exposure likely has some bearing on transmission of infectious particles as well and this has not been carefully studied. Examples of close contact include sharing eating or drinking utensils, physical examination, or any other contact between persons likely to result in exposure to respiratory droplets. Close contact typically does not include activities such as walking by an infected person or sitting across from a symptomatic patient in a waiting room or office.
What antiviral medications are available to treat Influenza?
Presently, four antiviral medications are available to treat patients with suspected or documented influenza. These are the adamantanes rimantadine (Flumadine) and amantadine (Symmetrel), and the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza).
How do I know which antivirals are appropriate to prescribe for my hospitalized, or high risk patients, or for healthcare workers?
If the only viruses circulating in a community are Novel H1N1, Seasonal H3N2 and/or Influenza B, then either oseltamivir (Tamiflu) OR zanamivir (Relenza) are the agents of choice because these viruses are all susceptible to these antivirals. However, if Seasonal H1N1 Influenza virus begins to circulate along with these other viruses, treatment with either zanamivir or combination therapy using oseltamivir PLUS amantadine or rimantadine is necessary due to resistance of Seasonal H1N1 virus to oseltamivir. Once laboratory testing reveals the patient's actual Influenza virus subtype, empiric antiviral therapy can be adjusted accordingly.
How do I know which Influenza viruses are circulating in the community?
The Clinical Microbiology Laboratory will keep physicians advised on an ongoing basis as to which influenza viruses we are seeing in the community in order to help guide appropriate empiric antiviral therapy.
What is the appropriate isolation precautions for ambulatory and hospitalized patients with Influenza-Like Illness (ILI)?
All patients who have (ILI) who require clinic evaluation and/or admission to the hospital should be placed in Enhanced Droplet/Contact isolation immediately upon admission. Do not wait for influenza laboratory test results to place admitted patients with ILI into isolation. Ordering any influenza diagnostic test constitutes clinical suspicion that a patient has influenza, and all such patients should be placed in Enhanced Droplet/Contact isolation concomitant with ordering the test.
What, exactly, is meant by "Enhanced Droplet/Contact Isolation Precautions"?
This level of isolation precautions must be ordered upon Suspicion of Influenza, and when ordering Influenza testing. Enhanced Droplet/Contact Precautions includes the following:
  • Private room or cohort patients
  • Door may be kept open
  • Hand hygiene on entering and leaving room
  • *Standard mask* and gown for patient care
  • N95 mask and eye protection when performing aerosol-generating procedures (e.g. nasopharyngeal swabbing, aspiration of respiratory tract, intubation, resuscitation, bronchoscopy, autopsy)
  • Gloves for patient care
  • Patient wears mask and gown for transport
  • Dedicate equipment to room if possible
How can I prevent the spread of Influenza virus in the healthcare setting?
Every effort should be made to train all healthcare workers as well as registration and admissions personnel to screen for and recognize ILI. Patients suspected of ILI should have a regular surgical mask placed over their mouth and nose, as this has been shown to be effective at preventing patients with influenza from infecting others. In the ambulatory clinic setting, separate waiting areas should be designated for ILI patients, and Droplet/Contact Precautions signs should be placed on the doors of examination rooms into which ILI patients have been placed in order to alert healthcare workers entering the room to wear appropriate personal protective equipment. Posting of "cover your cough signs" and providing healthcare workers and patients with facial tissues and alcohol-based hand sanitizer are also good practices.
Why are we presently being told that we can wear a regular surgical mask instead of an N95 particulate mask to enter the room of a patient with suspected or documented Novel H1N1 Influenza?
Although there remains some disagreement among experts, present knowledge on the transmission of Novel H1N1 influenza suggests that it is transmitted by similar routes to that of seasonal influenza, for which surgical masks are indicated for patient contact. N95 masks, in addition to eye protection such as that offered by goggles or a face shield, should be worn for selected procedures that are potentially aerosol-generating (e.g. obtaining a nasopharyngeal swab specimen from a patient, bronchoscopy, intubation, CPR, open airway suctioning, and sputum induction).
What is the hospital policy regarding patient visitation now that we are seeing so much influenza in the community and the hospital?
Effective immediately and until further notice, visitation of patients in all hospital areas is restricted to only one visitor at a time. No one under the age of 18 will be allowed to visit unless such an individual is the parent of a patient, because school age children represent one of the highest risk groups for shedding and spreading influenza to others. Compassionate visitation exceptions will be made on a case-by-case basis, and patient information will be distributed to explain this policy to parents, family members and visitors of our patients.
As a healthcare worker, what should I do if I become sick with Flu-like symptoms at home or during my time at work?
Healthcare workers should be monitored and should self-monitor for development of symptoms consistent with an influenza-like illness. If such symptoms develop, the healthcare worker should do the following:
  • Do not come to work if you have ILI, and notify your supervisor if you develop Flu-like symptoms at home
  • If you become sick at work:
    • Notify your supervisor
    • Suspend patient care duties immediately
    • Place a surgical mask over your nose and mouth
    • Get tested for Influenza by RT-PCR and get yourself evaluated so that you can receive empiric antiviral therapy while you are waiting for Influenza test results
    • Go home
    • If you are documented as having Influenza, you may not return to work for 7 days OR until 24 hours after your fever and Flu symptoms have resolved, whichever is longer
As a healthcare worker who becomes ill with Flu-like symptoms, how do I get tested and treated for influenza?
A plan for rapid testing and evaluation of healthcare workers for influenza-like illness is being developed. Until we have a plan in place, each situation will be dealt with on a case-by-case basis. Please contact Infection Prevention and Control for guidance at 323-6337. We will update this document with further information once it becomes available.
As a healthcare worker, what should I do if I think I have had an unprotected close contact exposure with a person (e.g. patient, colleague, co-worker, family member) who has suspected or documented Influenza?
Healthcare workers must report suspected close contact exposures to someone suspected or documented as having influenza. Examples of such exposures include, but are not limited to living in a household with a person with suspected or documented influenza, examining a patient with suspected or documented influenza without wearing appropriate personal protective equipment (PPE), and working with respiratory equipment and secretions of, or obtaining a respiratory secretions sample from a patient with suspected or documented influenza without wearing appropriate PPE. Follow the same guidelines above as if you were sick with Flu-like symptoms.
What if I get sick with influenza but I have exhausted my sick-leave?
Absence from work will undoubtedly cause anxiety among healthcare workers worried about excessive sick leave. Healthcare workers and supervisors are advised to work closely with Human Resources (HR) professionals to resolve absence issues. The UK Human Resources Department has developed a FAQ document to help answer many of the questions related to this issue that they have been fielding, and this should be reviewed to answer these and other questions.
What can we expect to see this winter as a result of the Novel H1N1 Pandemic?
Several burdens on healthcare delivery are to be expected this fall and winter as we enter the anticipated peak in the Novel H1N1 pandemic. Successful planning for an influenza pandemic is based on the following assumptions:
  • We will see an overwhelming surge in outpatient/inpatient volume
    • Influenza patients
    • "Worried well" with other respiratory infections
  • We will likely experience workforce shortages of up to 30-40% for 4-8 weeks during the height of the pandemic
    • Anticipate taking on tasks that are not usually your responsibility
  • We will have to deal with basic supply shortages
    • PPE: masks, gowns, gloves
    • Anything that has to be delivered to the hospital, clinic, or office: medical supplies, food, soap, paper towels, alcohol-based hand sanitizer, toilet paper
    • Viral culture media, rapid influenza tests
    • Antiviral medications
    • Patient ventilators, monitors
  • We are likely to experience an uncomfortable, if only temporary, diminution of our usual standard of care; anticipate "Business NOT as usual"
What can I do to prepare?
The key to being ready is to start now to develop plans for how your facility, department, service line or care area will deal with the above issues. This involves activation of leaders at all levels to come together and prepare a comprehensive plan in order to be ready.

Ambulatory Setting
  • Know ILI symptoms; look for them in every patient as they arrive
  • Educate your entire staff to look for and recognize ILI when they see it
  • Develop a rapid, up-front triage system for ILI
    • Train registration personnel to screen each patient
    • Immediately provide surgical masks to ILI patients
    • Designate a separate waiting area for ILI patients
    • Put up "Cover Your Cough" signs, offer patient education materials
  • Cross-train all clinic staff so that critical tasks can be completed even with key personnel out sick
  • Discourage staff with ILI from coming to work sick
  • Work with HR to excuse ILI-related absences
  • Develop an Emergency Operations Plan (a.k.a. Continuation of Operations Plan, "COOP")
    • Designate leadership (and backup) roles
    • Identify critical services that cannot be interrupted
    • Identify non-critical services that can be temporarily suspended in order to focus on critical services
    • Develop a rapid triage plan for patients, rapid patient assessment forms (e.g. UHS, Pediatric Clinic have nice examples), pre-written prescriptions
    • Work with Materials Management to make certain that they have stockpiled critical supplies
  • Monitor for unexpected surge in ILI patients presenting to your clinic/office
  • Establish "threshold" at which "business as usual" is no longer possible and your emergency operations plan goes into effect
  • Establish criteria for hospital admission
Hospital Setting
  • Develop an Emergency Operations Plan
    • Designate leadership (and backup) roles
    • Identify a "threshold" point at which:
      • Elective surgeries, admissions and procedures are postponed
      • Discharges are expedited (care by parent education, discharge rounds, "middle of the night" discharges)
      • "Double-bunk" bed assignments are made
  • Work with Materials Management to make certain they have stockpiled critical supplies for you
  • Develop a ventilator allocation protocol

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Page last updated: July 18, 2012