1. INFLUENZA Caring for our Caregivers AND Our Patients ~ Our Community
09/29/09 Janice Parker, APRN, Employee Health Services

2. This graphs pediatric deaths due to flu year-to-year.
It shows how flu season usually builds and peaks around January to March, then disappears over the summer.
EXCEPT this year. You can see the second peak and that it hasn’t disappeared at all.

3. This graph is just THIS year & shows the incidence of confirmed US flu cases. Again you can see the double peak and that the flu has continued without returning to the previous baseline.
So, as the normal flu peak builds from this new baseline– that’s a lot of sickness. Sick staff with sick families – unable to care for our sick patients A serious problem.

4. Seasonal Influenza Key Facts
The flu is a contagious respiratory illness
Every year in the United States, on average:
5% to 20% of the population gets the flu;
more than 200,000 people are hospitalized from flu-related complications (a high of 430,960);
about 36,000 people die from flu-related causes (a high of 52,000).
So, lets be sure we really understand what the flu is.
First - the seasonal flu
It is a respiratory illness (not the “stomach flu”)
At minimum, it is inconvenient – up to a fifth the pop getting it;
it’s devastating – ¼ - ½ a million hospitalized;
and it’s deadly

5. Seasonal Influenza Symptoms of flu include:
abrupt onset of fever (usually high)*
headache
extreme tiredness*
dry cough
sore throat
runny or stuffy nose
muscle aches
Stomach symptoms, such as nausea, vomiting, and diarrhea, also can occur but are more common in children than adults
* unlike a cold
The fever; extreme fatigue are what distinguishes the flu from a cold

6. Healthcare personnel should not
be at work
if they have a fever*
*100º F or greater
PERIOD. I’ll go over the protocol for how we are to manage staff who have been exposed to or develop the flu

7. Seasonal Influenza ~ transmission
How Flu Spreads
person to person through coughing or sneezing
sometimes by contact with something with flu viruses on it and then touching mouth or nose
The virus can survive and can infect a person for up to 2-8 hours after being deposited on a surface
Strong, long-lasting virus on surfaces – so it can spread even without a cough or sneeze. That’s an important fact because . . .

8. Seasonal Influenza ~ transmission
Healthy adults may infect others
1 day before symptoms develop
and up to 5 days after becoming sick.
Some healthy adults are infected
and have very mild symptoms or none at all
Healthcare workers may pass on the flu before they know they are sick.

9. Seasonal Influenza ~ Health-Care Personnel
HCP are considered “a source of influenza virus transmission” (ACIP)
Decreasing transmission from caregivers reduces flu and complications among persons at high risk
Healthcare workers and children are considered the main groups who spread the flu.

10. Seasonal Influenza ~ PREVENTION
Vaccination
Meticulous hand hygiene
Respiratory & cough etiquette
Environmental hygiene
Work restrictions

11. Seasonal Influenza ~ PREVENTION
Meticulous hand hygiene
Have both gloves and hand cleaner CONVENIENTLY available at all times
For staff, patients and visitors
Expect people to USE them!
Respiratory & cough etiquette
Have masks, tissues and waste containers CONVENIENTLY available at all times
Environmental hygiene
Cleaning everything touched by staff & patients is more important than ever.
Work restrictions – STAY HOME when ill!
I’ll discuss staff work restriction guidelines in more detail.

12. Seasonal Influenza ~ vaccination
The single best way to prevent the flu is to get a flu vaccination each year.
Influenza outbreaks in hospitals attributed to low vaccination rates among healthcare workers
Vaccination both of HCW & patients provided significant reductions in deaths
#1 reason employees give me for not getting a flu shot is that they’re healthy. They are missing the point. Protecting yourself is only part of the reason to get vaccinated. It also protects others –co-workers, patients, family, friends, community . .

13. Seasonal Influenza ~ Health-Care Personnel
ACIP recommends that health-care administrators consider the level of vaccination coverage among health-care personnel (HCP) to be one measure of a patient safety quality program and implement policies to encourage HCP vaccination (e.g., obtaining signed statements from HCP who decline influenza vaccination).
The Infectious Diseases Society of America has recommended mandatory vaccination for HCP, with a provision for declination of vaccination based on religious or medical reasons.
The Joint Commission on Accreditation of Health-Care Organizations has an accreditation requirement (beginning January 1, 2007) that requires accredited organizations to offer influenza vaccinations to staff.
The pressure is on to immunize HCW. . . JCAHO = offer; IDSA = make mandatory; ACIP = make it one measure of a patient safety quality program

14. Seasonal Influenza ~ Health-Care Personnel
CDC/ ACIP ~
“Health-care facilities should offer influenza vaccinations to all HCP, including night, weekend, and temporary staff.
Particular emphasis should be placed on providing vaccinations to workers who provide direct care for persons at high risk for influenza complications.
Efforts should be made to educate HCP regarding the benefits of vaccination and the potential health consequences of influenza illness for their patients, themselves, and their family members.
All HCP should be provided convenient access to influenza vaccine at the work site, free of charge, as part of employee health programs.”
Offer it to ALL; emphasize direct care givers; educate; make it free & convenient

15. Seasonal Influenza ~ vaccination
Vaccine effectiveness
when the vaccine and circulating viruses are well-matched
prevents illness among approximately 70%-90% of healthy adults aged <65 years
when the vaccine strains are not well-matched to the majority of circulating strains
Effectiveness against influenza illness 50%-77%
However, effectiveness among healthy adults against influenza-related hospitalization was 90%
antibodies develop within two weeks after vaccination
protection lasts up to one year
flu vaccines will not protect against flu-like illnesses caused by non-influenza viruses.
In “good” years Even in “bad” years the effectiveness makes it worthwhile

16. Seasonal Influenza ~ vaccination
Who Should Not Be Vaccinated
without first consulting a physician
People who have a severe allergy to chicken eggs.
People who have had a severe reaction to an influenza vaccination in the past.
People who developed Guillian-Barre syndrome within 6 weeks of getting an influenza vaccine previously.
People who have a moderate or severe illness
with a fever should wait
(they should not be at work!)
There are very few people with a valid medical reason not to be vaccinated. Severe allergy/ reaction is defined as an anaphylactic reaction – not a rash

17. Seasonal Influenza ~ vaccination
Side Effects
the most frequent side effect of vaccination:
soreness at the vaccination site
typically mild
the flu vaccine is not associated with higher rates for systemic symptoms (e.g., fever, malaise, myalgia, and headache) when compared with placebo injections
THE FLU VACCINE CANNOT CAUSE THE FLU
Studies show that the only side effect that occurs more often with a flu shot than a placebo is soreness at the injection site

18. nH1N1 Influenza Signs and symptoms fever,
respiratory tract illness (cough, sore throat, runny nose),
headache,
muscle aches
some cases have had vomiting and diarrhea
Looks just like the seasonal flu

19. nH1N1 Influenza
“Currently the 2009 H1N1 influenza virus (sometimes called “swine flu”) virus seems to be causing serious health outcomes for:
healthy young people from birth through age 24;
pregnant women;
and adults 25 to 64 who have underlying medical conditions.”
CDC, 09/17/09
Our employees, our community and our patients

20. nH1N1 ~ PREVENTION Vaccination Meticulous hand hygiene
Respiratory & cough etiquette
Environmental hygiene
Work Restriction
The same as the seasonal flu.
PREVENTION is THE most important thing we can do. As you’ll see, it’s gets a little complicated when we have to deal with situations where preventive measures were not taken. PLEASE encourage and enforce the use of these measures with your staff.
We’re discussing a competition to encourage vaccination with the H1N1 vaccine to try to improve our level of protection. You’ll be getting more information about it.

21. Vaccination Planning ~ novel H1N1
Vaccine trials have shown excellent immunity after a single dose of inactivated vaccine for ages 10 and up
People who have a severe (life-threatening) allergy to chicken eggs or to any other substance in the vaccine should not be vaccinated.
The vaccine will be released from federal to state public health, then to us
gradually, beginning in October
NH DHHS ‘alert’ on 09/25/09
Live, nasal mist vaccine will arrive first of October
Inactivated vaccine will be available mid-to-late October
When talking to your staff, it’s helpful to realize that even though it’s unusual to get 2 doses of flu vaccine, if this strain of flu had come earlier it probably would have just been included in the annual flu vaccine. It is considered to be a safe and effective vaccine.

22. INFLUENZA & Healthcare Workers
MINIMUM Infection Control measures
NH DHHS guidelines for healthcare settings
Standard Precautions
Droplet Precautions
Surgical Mask when entering the room; or when within 6 feet of influenza-like illness (ILI)
Meticulous Hand Hygiene
Respiratory Hygiene & Cough Etiquette
Early Recognition & Separation of those Infected
Restriction of Visitors & HCWs with ILI
When the ill person is in a ‘community area’ – for example Registration/ Lobby, THEY should be asked to wear a mask to protect everyone around them. On entering a patient’s room, the STAFF should be wearing the mask.
NH DHHS will be updating their guidelines in 2 weeks, but for now we need to review the guidelines we have been given. One question asked of Public Health was whether all of the restrictions applied to immunized staff - they’ll get back to us on that.

23. ~ FRISBIE STAFF ~ Flu Exposure & Illness Algorithms
Based on the guidelines from the NH DHHS
Subject to change when updated in mid-October
May (or may not!) be different if the staff member has been immunized against seasonal and H1N1 influenza viruses

24. Algorithm #1 ~ What to do if Frisbie direct patient care givers are exposed to the flu
NOTE that this is specific to direct patient care givers.
You can see from the definitions that this involves some staff education.

25. Algorithm #2 ~ Frisbie Direct Patient Care HCW* who develop ILI*
This protocol is similar to what we do for body fluid exposures. Employee Health will follow-up during our hours. The Nursing Supervisors can instruct staff after hours & on weekends. ED providers will be needed to do testing &/ or write prescriptions.
AGAIN, prevention is important to avoid as much of this as possible.

26. Algorithm #3 ~ Frisbie Staff Testing & Treatment
HCW sent to Employee Health or ED for PEP, TESTING, TREATMENT
Does HCW have symptoms of ILI*? NO
PEP only
1. Prescribe PEP*
(call Rx to employee's drug store)
& instruct employee to:
a. wear a surgical mask at work
until PEP is started;
b. have Rx filled, c. & begin PEP ASAP OR
2. instruct to wear a surgical mask
while at work for 7 days.
YES
Did HCW have patient contact*
24 hours before or after symptoms began?
YES
TEST* NO
Exposed employees without symptoms can continue to work – but they need to wear a mask until PEP can be started. Our Pharmacy cannot provide the anti-virals, so the employee will have to get it from their drug store as soon as possible.
Is HCW in high risk category*?
YES
TREAT* Prescribe anti-viral
2. Send home & instruct:
a. Stay home until no fever (100ºF or higher)
for 24 hours without anti-fever medication
b. Wear a mask after return to work
until no symptoms such as cough NO
Send home & instruct:
1. Stay home until no fever (100ºF or higher)
for 24 hours without anti-fever medication
2. Wear a mask after return to work
until no symptoms such as cough

27. FRISBIE STAFF ~ FLU TESTING & TREATMENT (* see definitions)
the following groups ONLY
HCW* with ILI* with direct patient contact during infectious period (24 hours before symptoms to 7 days after symptoms started)
IF recent onset fever (100ºF or higher) with cough and/ or sore throat AND
Hospitalized patients
Requested by Public Health
nasopharyngeal swab, aspirate or wash for influenza PCR testing
Post Exposure Prophylaxis
Begin within 24 hours of exposure & continue until 10 days after last unprotected exposure*
PEP* for adults
Oseltamivir 75 mg orally once daily
Zanamivir 10 mg inhaled once daily
TREATMENT
Begin within 48 hours of start of symptoms
IF at high risk of complications* or severely ill (hospitalized)
Treatment for ill adults
Oseltamivir 75 mg orally twice daily for 5 days
Zanamivir 10 mg inhaled twice daily for 5 days

28. ~ How You Can Help ~ Get your flu shot(s) ~ set an example
Educate & encourage your staff; Confront misconceptions & misinformation with the facts
Help me schedule flu shot clinics that reach your staff most efficiently & effectively
ENFORCE PREVENTIVE MEASURES ~
Meticulous hygiene with patients, visitors & staff
Hand hygiene, cough etiquette & environmental
Work restrictions with your staff
NO ONE is to come to work with a fever
Set a good example - if you can have the vaccine, get it;
help dispel some of the myths about flu vaccine, share this information at staff meetings, in casual conversation & whenever you hear myths & misinformation being spread.
Let me know how to most efficiently & effectively reach your staff for flu shots.
Be consistent in your enforcement of these other very important preventive measures

29. Thanks!