Staff Awareness:Infection Control For Viral Respiratory Infections Pandemic flu, Seasonal flu and Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Seasonal Flu Pandemic FluOutbreaks follow predictable seasonal patterns; occurs annually, usually in winter, in temperate climates

Usually some immunity built up from previous exposure

Healthy adults usually not at risk for serious complications; the very young, the elderly and those with certain underlying health conditions at increased risk for serious complications

Occurs rarely (three times in 20th century last in 1968)

No previous exposure; little or no preexisting immunity

Healthy people may be at increased risk for serious complications

Seasonal FluSo seasonal flus impact on a society is less severe than a pandemic, but it is, in many countries a yearly risk that must be managed effectively by the public health care authorities in order to protect vulnerable people and to contain its impact on society. Control methods include influenza vaccines (flu shots and nasalspray vaccine) that can be taken by all members of society but must be promoted aggressively and completely funded by government public health care agencies for vulnerable people and health care workers to reduce the impact on public health and to ensure business continuity for health care facilities. Other measures that will help reduce spread are:

•Respiratory hygiene which must be promoted across all healthcare facilities and through public promotion in the media for community health care education •Encourage people to stay at home if they have flu they should completely isolate themselves and avoid contact with other family member’s as much as possible using respiratory hygiene and contact and droplet transmission precautions. •Ensure appropriate length of sick leave is given to avoid infected sick people having to attend the health centers just to get more sick leave.

Below is a comparison table between seasonal flu and pandemic fluIntroductionPandemic flu and other viral respiratory infections such as Seasonal flu,H1N1, Middle East Respiratory Syndrome Coronavirus (MERS-Cov) have the same modes of transmission droplet and contact which are constant and airborne which is a risk when performing aerosol producing procedures that induce coughing and these aerosols can stay suspended in the air longer and travel further than droplets. However all these infections have different risk factors associated with them specifically looking at contagion risk, the actual impact on the patient, and the ability of that patient to fight the infection. So risk assessment is essential to identify the different risks to the different population groups in order to manage all three infection risks effectively reducing the impact on patients, staff and health care delivery. Infection control and prevention strategies should be consistent with those used to prevent transmission for infectious agent in all health care settings. Hierarchical controls such as administrative controls, environmental/engineering controls and personal protective equipment must be properly observed and applied.

Modes of TransmissionDroplet transmission an infection acquired by the inhalation of pathogenic microorganisms suspended in particles of liquid exhaled, sneezed, or coughed by another infected person or animal.Contact transmission an infection acquired by touching a patient or their bodily fluids directly (direct contact) or by touching the patients surrounds that have been contaminated (indirect contact).Airborne transmission an infection spread as an aerosol that can stay suspended in the air for extended lengths of time and usually enters a susceptible person through the respiratory tract.

Seasonal Flu vs. Pandemic fluInfluenza viruses are common worldwide phenomena and happily travel the globe very easily these days with modern methods of transportation.As they travel around and infect people, the human populations exposed build resistance and immunity and although research has shown the influenza virus like all viruses does change and mutate over time most people have some immunity from previous exposures, so only immune deficient populations are at high risk of mortality. With pandemic flu it is an outbreak of flu disease of a new type of influenza virus that people have not been exposed to before. It becomes a pandemic and worldwide public health emergency because it can travel around the world so quickly and be life threatening to all members of society.

The first point here, respiratory hygiene is a new concept worldwide we all have been brought up to cover our mouths with our hand when we cough!! This new initiative is asking us to cough into our elbow, it is difficult to change the ritual behaviors we learn as kids and do on “autopilot” without thinking, especially when humans like to fit in with the crowd, so feel self conscious when doing something different!!

Pandemic FluPandemic Flu is different from any other major public health threat because it is highly contagious and can kill millions, as we have evidence of in previous pandemic outbreaks in the last century, the Asian flu pandemic killed 2 million people in 1957, the Spanish flu killed 40 to 50 million in 1918.

However looking at things from a risk management perspective today we have on the negative side more cross border migrations and much more occupational and holiday travel which can spread infection without impunity. On the positive side we have antiviral medications that can be ready to use as part of an initial emergency preparedness plan, followed by the ability to prepare a vaccine quite quickly specifically targeting the new flu virus mutation as part of the follow up action plan. All countries were stressed when the H1N1 flu (swine flu) virus was identified.All responded differently and from the initial thought that it was a major global health threat all countries resorted to their emergency preparedness plan to deal with the situation and all precautions were taken. However as events happened and data was analyzed it was reveal that this particular virus was not as virulent as feared. People were not dying in their thousands!!! The outbreak past fairly pain free and swine flu was added to the seasonal flu vaccine for the following year routine flu vaccine shot. However the positive side of this occurrence is the fact that public health agencies around the word have had a “dummy run” to prepare the needed resources and have the needed business continuity plan in place to cope with the “real thing” the flu virus that will kill indiscriminately!!!

Occupational exposure to pandemic influenzaAs health care workers you are at particular risk from becoming infected so must ensure you follow both PHCC policies and procedures and current health care warnings from the Supreme Council of Health (SCH) and from global organizations such as World Health Organization (WHO) and Centers for Disease Control (CDC).

*Protect yourself, family and others

IMPORTANT NOTEMiddle East Respiratory Syndrome Coronavirus (MERS-Cov)

MERS-CoV is Middle East Respiratory Syndrome Coronavirus, a novel corona virus.A. Coronaviruses are a large family of RNA viruses causing a range of acute respiratory illness (SARS was also in this family of coronaviruses)

Major PresentingSymptoms: • Fever • Cough • Dyspnea/Shortness of Breath

Other common presenting symptoms include: • Chills • Rigor • Headache • Myalgia • Malaise • Mild disease and atypical presentation with diarrhea have also been reported

Major Complications: • Respiratory Failure in severe cases • Severe cases have all had underlying comorbidities

Common laboratory features include: • Infiltrates on chest radiographs • Lymphopenia • In some cases: thrombocytopenia, elevated lactate dehydrogenase, aminotransferase and creatine kinase levels

Incubation Period: •Estimated median incubation period was 5.2 days (1.9 to 14.7 days)

Transmission:

• Coronaviruses are mainly transmitted by large respiratory droplets and direct or indirect contact with infected secretions. • Fecal-oral transmission may also be possible via diarrhea. • Evidence indicates that coronaviruses may also be transmitted through airborne, virus containing aerosols • Personal protective equipment and good infection control are extremely important

Treatment:

• There is no current treatment specific to MERS-CoV, only supportive herapy as required

Prevention: • There is no current vaccine to prevent infection • The best way to prevent infection is to use appropriate respiratory hygiene and PPE when indicated • Healthcare facilities must use appropriate and strict infection control measures

Infection Control and Prevention Measures General Environmental:

• Ensure adequate environmental ventilation and cleaning in all areas within the health care facility • Maintain spatial separation of at least 1meter between each acute respiratory infection patient and others, including healthcare workers (when not using PPE)

Isolation precautions: • Use contact and droplet precautions • Add airborne precautions if performing any aerosol generating procedures • Limit the number of people in the room to absolute minimum for patient evaluation or care. Have same team for full shift. • All procedures and investigations should be carried out in the single room

Personal Protective Equipment (PPE):To be worn by anyone coming within 1 meter contact withthe suspected confirmed case:

• Surgical mask for routine care and testing • N95 mask if performing an aerosol generating procedure • Gloves • Long sleeved fluid repellent gown • Eye protection with 1 meter of contact, if splash or spray with respiratory secretions is suspected, wear goggles or face shield

Hand Hygiene:

•Perform hand hygiene (WHO 5 moments of hand hygiene)

•Hand hygiene includes either washing hands with soap and water or the

use of an alcohol based hand rub.

•Wash hands with soap and water when they are visibly soiled

•Rings (other than a plain smooth band), wrist watches and wrist jewelry

must not be worn by staff

Patient care equipment: •If possible use dedicated/disposable equipment in the isolation room •If reusable equipment are used it should be autoclaved as per policy after use •Keep patient care supplies to a minimum in the room •Follow standard practices for handling and reprocessing used patient care equipment, including medical devices •Wear gloves when handling and transporting used patient care equipment •Wipe heavily soiled equipment with an EPA approved PHCC disinfectant before removing it from the patient's room •Follow current PHCC policy for cleaning and disinfection or sterilization of patient care equipment •Wipe stethoscopes with alcohol or disinfectant after use with suspected/ confirmed case

Linen (if applicable): •Bag linen inside isolation room (area) •Linen should be bagged in accordanc with normal PHCC procedures for infected linen and the laundry informed of the high risk nature

Waste: •Contain and dispose medical waste in accordance with PHCC specific procedures and/or local regulations for handling and disposal of medical waste,including used needles and other sharps

•Discard as routine waste used patient care supplies that are not likely to be contaminated (e.g., paper wrappers) •Wear disposable gloves when handling waste. Perform hand hygiene after removal of gloves

Cleaning and disinfectionof isolation rooms/areas:•Environmental services personnel should wear PPE, be trained in proper procedures for PPE use, including removal of PPE, and the importance of hand hygiene •Keep cleaning supplies outside the room in isolation baskets•Use routine PHCC health center approved detergent disinfectant; follow manufacturer's recommendations for use dilution (i.e.,concentration), contact time, and care in handling•Clean and disinfect all surfaces that were in contact with the patient or may have become contaminated during patient care•Clean and disinfect isolation room/area at every shift and more often when visible soiling/contamination occur; special attention to frequently touched surfaces (e.g., exam tables, telephone, doorknobs, chairs); and floors and other horizontal surfaces •After an aerosol generating procedure (sputum induction, nebulization therapy ), clean and disinfect horizontal surfaces around the patient as soon as possible after the procedure •No special treatment is necessary for window curtains, ceilings, and walls unless there is evidence of visible soil

Specimens:All specimens should be regarded as potentially infectious, and HCWs who collect or transport clinical specimens should adhere rigorously to Standard Precautions to minimize the possibility of exposure to pathogens. •Ensure that all healthcare workers who collect specimens wear appropriate PPE •Ensure that personnel who transport specimens are trained in safe handling practices and spill decontamination procedures. •Place specimens for transport in leak proof specimen bags with the patient’s label on the specimen and a clearly written request form •Ensure that health care facility laboratories adhere to appropriate bio afety practices and transport requirements according to the type of organism being handled •Deliver all specimens by hand whenever possible •State suspected MERS-CoV sample clearly on the accompanying request form •Notify the laboratory as soon as possible that the specimen is being transported •Specimens should be stored at 4 degrees Celsius until testing performed

Respiratory hygiene/cough etiquette

Respiratory hygiene/cough etiquette consists of practices which are aimed at the prevention or reduction in the transmission of respiratory infections. To implement respiratory hygiene/cough etiquette in our health centers and to change people’s behaviour to use it, we need to provide information and resources.

•Educating staff, patients, and visitors about the spread of respiratory illnesses •Posting signs on how to follow respiratory hygiene/cough etiquette in public areas

•Instructing individuals who are coughing and /or sneezing on the proper use of facial tissues (i.e., covering the mouth/ nose with a tissue, immediate disposal of tissue, and hand hygiene) •Providing a mask to coughing individuals •Healthcare staff wearing a surgical/ procedure mask when examining a patient or visitor with signs/ symptoms of respiratory illness •Instructing individuals to cough or sneeze into the elbow or upper sleeve •Separating potentially contagious individuals by at least 3 to 6 feet from others

Step 1. Perform Hand Hygiene

• Alcohol based hand rub is the preferred way to clean hands.

• When hands are visibly soiled, wash with soap and water.

*Note: If pertorming an aerosol - gerenting rcocedure, a particulate respinating should be used in combinayion with face shield or goggles /eye protection

Putting on (Donning)

PERSONAL PROTECTIVE EQUIPMENTThe type of PPE used will vary based on the level of precaution required e.g., Standard and Contact, Droplet or Airborne Infection Isolation.

Step 4. Put on Mask /Respirator or Face shield

Step 5. Put on Gloves

• Secure ties or elastic bands at middle of head and neck.• Fit flexible band to nose bridge.• Fit snug to face and below chin.• Perform seal check when using a particulate respirator (N95).

Put on gloves over cuff.

Step 3. Put on Head Cover

Wear head covers to protect the hair and scalp from possible contamination when sprays or airborne exposure is anticipated.

Step 2. Put on Gown

• Make sure the gown covers from neck to knees, arms to wrist, and wrap around the back.• Fasten in back of neck and waist.

For further information on seasonalflu, pandemic flu and MERS-CoV, please visit the following websites:

• http://www.cdc.gov/flu/other_flu.htm• http://www.flu.gov/• http://www.sch.gov.qa/sch/En/• http://www.phcc.gov.qa

• Perform hand hygiene using alcohol based hand rub or washing with soap and water.

Step 4. Remove Mask/Respirator or Face shield

Step 5. Remove Head cover

Step 6. Perform Hand Hygiene

• Carefully, remove mask

• Discard in waste container.

• Carefully, remove head cover from inside out.• Discard in waste container.

Step 2. Perform Hand Hygiene

•Alcohol basedhand rub is the preferred way to clean hands.•When hands are visibly soiled, wash with soap and water.

Step 3. Remove Gown

•Peel off gown and roll from inside out.•Dispose safely in waste container.

Step 1.Remove Gloves

Taking Off (Doffing)

• Peel off gloves carefully.• Discard gloves in waste container

PERSONAL PROTECTIVE EQUIPMENTThe type of PPE used will vary based on the level of precaution required e.g., Standard and Contact, Droplet or Airborne Infection Isolation.

For inquiries, contact Risk Management: 44597835 or Email: risk@phcc.gov.qa

Be informed. Make a plan. Get involved