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Extremely obese individuals, those with a BMI (body mass index) of over 40, have a significantly higher chance of dying from 2009 A(H1N1) swine flu infection compared to other people, researchers revealed in the journal Clinical Infectious Diseases. The scientists gathered data from a public health surveillance database in California and found extreme obesity to be a “powerful risk factor for death”.

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Infection prevention and control in health care in providing care for confirmed or suspected A(H1N1) swine influenza patients

Background

The current situation regarding the outbreaks of A(H1N1) swine influenza is evolving rapidly, and countries from different regions of the globe have been affected. Based on epidemiological data, human-to-human transmission has been demonstrated along with the ability of the virus to cause community-level outbreaks which together suggest the possibility of sustained human-to-human transmission. Health-care facilities now face the challenge of providing care for patients infected with A(H1N1) swine influenza. It is critical that
health-care workers use appropriate infection control precautions when caring for patients with influenza-like symptoms, particularly in areas affected by outbreaks of A(H1N1) swine influenza, in order to minimize the possibility of transmission among themselves, to other health-care
workers, patients and visitors.

As at 29 April, human-to-human transmission of A(H1N1) swine influenza virus appears to be mainly through droplets. Therefore, the infection control precautions for patients with suspected or confirmed A(H1N1) swine influenza and those with influenza-like symptoms should prioritizethe control of the spread of respiratory droplets. The precautions for influenza virus with sustained human-to-human transmission (e.g. pandemic-prone influenza) are described in detail in the
document “Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care WHO Interim Guidelines” 1.
This guidance may change as new information becomes available.
Fundamentals of infection prevention strategies

The WHO Interim Guidelines”1.

This guidance may change as new information becomes available.

Fundamentals of infection prevention strategies

1. Administrative controls are key components, including: implementation of Standard and Droplet Precautions; avoid crowding, promote distance between patients (= 1 m); patient triage for early detection, patient placement and reporting; organization of services; policies on rational use of available supplies; policies on patient procedures; strengthening of infection control infrastructure.

2. Environmental/engineering controls, such as basic health-care facility infrastructure 2 , adequate ventilation, proper patient placement, and adequate environmental cleaning can help reduce the spread of some respiratory pathogens during health care.

3. Rational use of available personal protective equipment (PPE) and appropriate hand hygiene.
For more details, see Essential environmental health standards in health care. Geneva, World Health Organization, 2008.

CRITICAL MEASURES:
Avoid crowding patients together,
promote distance between patients
Protect mucous of mouth and nose
Perform hand hygiene

The recent H1N1 pandemic has highlighted the importance of identifying public health measures which can help to mitigate flu virus transmission. Researchers conducted a prospective cluster-randomized trial to test whether improved hand hygiene or surgical face masks could reduce the spread of flu within households.

The researchers studied 407 people with flu-like symptoms who visited one of 45 outpatient clinics across Hong Kong within 48 hours of symptom onset, had rapid tests that confirmed infection with influenza A or B, and lived in a household with at least two other individuals, none of whom had reported flu symptoms in the preceding 14 days. The flu patients plus their household members were randomly assigned to one of three groups: control, control plus enhanced hand hygiene, and control plus enhanced hand hygiene plus face masks.

The researchers found that hand hygiene appeared to be effective at preventing household transmission of the flu virus only when implemented within 36 hours of symptom onset. These findings have important public health implications, as they suggest that non-pharmaceutical interventions can reduce flu transmission if implemented early after symptom onset.

Source:
Angela Collom
American College of Physicians

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May 1, 2009 — The US government’s tentative plan to develop a stand-alone vaccine for the swine-origin H1N1 influenza virus could strain the nation’s vaccine makers to the point of reducing production of seasonal flu vaccine this fall, an official with the National Institutes for Health told Medscape Infectious Diseases .

It’s all a matter of striking a balance between the unknown threat of the H1N1 influenza virus and the known threat of the seasonal flu virus, said Gary Nabel, MD, director of the vaccine research center at the National Institute of Allergy and Infectious Diseases.

“There may have to be compromises,” said Dr. Nabel. “We’ll know more as time goes on.”

Balancing the supply of 2 different vaccines is just one challenge facing public health officials as they contemplate vaccinating Americans against a new flu virus that has resulted in 141 confirmed cases and 1 death in the United States, killed possibly 170 people in Mexico, and emerged in at least 9 other nations. Questions remain for public health officials about whether citizens will go to the trouble of getting both seasonal and H1N1 vaccines and how to reduce potential arguments over who in the general public should be the first to receive vaccination with the limited supplies of H1N1 vaccine in the fall.

Yesterday, Richard Besser, MD, acting director of the Centers for Disease Control and Prevention (CDC), said that the CDC is discussing a plan to manufacture a separate H1N1 vaccine — if it’s needed — after completing the production of next fall’s seasonal flu vaccine, which is now under way. The alternative, considered unrealistic, would be to delay production of the seasonal vaccine so that the H1N1 vaccine could be incorporated into it.

Vaccine makers would create a 2-dose regimen for the H1N1 vaccine — a primer dose at first, followed by second to “seal the deal,” said Christine Layton, PhD, MPH, a public health researcher and influenza pandemic expert at RTI International in Research Triangle Park, North Carolina. To immunize roughly 300 million Americans, therefore, the federal government would need 600 million doses. That’s 4 times the number of doses of seasonal flu vaccine that vaccine makers were projected to make for the 2008–2009 flu season, according to the CDC. “Production will be a big challenge,” said Dr. Layton.

Can the United States successfully conduct a 2-front war on flu viruses? On the bright side, experts say that our vaccine-making capacity is stronger than ever. During the 2004–2005 flu season, a single company, Sanofi Aventis, was putting injectable seasonal flu vaccines into the immunization pipeline. In 2009, 6 companies are licensed to manufacture seasonal flu vaccines in this country (one of them makes a nasal spray), and all of them are working to expand their production capacity, according to the CDC.

There are other positives. Dr. Nabel said the recipe for this fall’s seasonal flu vaccine will contain 2 of the 3 influenza virus strains used in the vaccine for the 2008–2009 flu season, making it easier to produce. That good fortune could help vaccine makers maintain adequate supplies of seasonal flu vaccine while pumping out an H1N1 version, he said.

Manufacturers also can stretch their supply of H1N1 vaccine by adding so-called adjuvants, which amplify the immune response. Growing vaccine-bound viruses in cell cultures as opposed to chicken eggs — the traditional and more cumbersome process — also promises to boost production, but not necessarily in 2009, added Dr. Nabel. “I doubt that it could satisfy the demand that is out there.”

All in all, said Dr. Nabel, the production equation depends on how severe the H1N1 virus outbreak turns out to be. To create enough H1N1 vaccine, it may be necessary to cut back on seasonal vaccine production, he said. That prospect troubles experts such as Dr. Layton, since seasonal influenza claims the lives of 36,000 people each year. “It’s not an inconsequential disease,” she said.

However, stinting on the supply of an H1N1 vaccine creates problems, too. As it is, the federal government envisions having 50 to 80 million doses of the H1N1 vaccine this fall, with the rest of the necessary doses becoming available later in the year as manufacturing continues.

“Early on, when the vaccine is in short supply, the biggest challenge will be determining how it will be administered in a way that’s epidemiologically appropriate and ethically sound,” said Dr. Layton. Faced with limited quantities, she said, the general public may fight over the vaccine just as shoppers sometimes fight over store merchandise on sale. “It’s an unfortunate part of human nature,” she said.

To be sure, the US Department of Health and Human Services probably will recommend a pecking order for who should receive any H1N1 vaccine, said Dr. Nabel. HHS took that same approach in gearing up for a possible avian flu pandemic 3 years ago, putting the vaccine and antiviral manufacturing workforce at the top of the list, followed by various types of healthcare workers, and then groups of vulnerable patients such as persons older than 65 years with 1 or more influenza high-risk conditions (not including essential hypertension) and pregnant women.

However, such priority recommendations are subject to debate. While healthy persons aged 6 to 64 years are on the bottom of the list for an avian flu vaccine, some have argued that healthy children should be closer to the top during a pandemic, said Dr. Layton. “Elderly persons — particularly those who are ill — often have minimal immune response to vaccines,” she said. “Young children, although potentially healthier than sick elderly persons, are more likely to have a robust immune response to immunization and pose a greater risk of spreading infection. [They] often are infectious for greater time periods than adults and come in contact with more people. As such, there are those who assert that young children are a more reasonable group to receive vaccines than frail elderly,” she said.

In addition to competing for production resources, separate seasonal and H1N1 vaccines also may confuse patients. “It will be a challenge for public health officials to explain to people what vaccines they’re getting, and what they’re good for,” Dr. Layton added.

The production and administration problems created by separate vaccines for the seasonal and H1N1 influenza will disappear if public health authorities decide to incorporate an H1N1 vaccine into the seasonal vaccine for the fall of 2010. They would have plenty of time to determine whether they should substitute the H1N1 virus for 1 of the 3 viruses used in the seasonal vaccine design, or whether they should make it a fourth component.

Then again, that’s assuming the H1N1 virus becomes the major health threat that people fear. As of now, the federal government is on course to produce a H1N1 vaccine, but it could later nix the idea of mass production if the new virus fizzles out. Making the right decision will be tricky, said Gigi Kwik Gronvall, PhD, a senior associate and immunologist by training at the Center for Biosecurity at the University of Pittsburgh Medical Center in Pennsylvania.

“You don’t know what the swine flu will do,” said Dr. Gronvall. “Biology is always full of surprises. The data changes from day to day, so you need to keep an eye on what’s going on and avoid both overreacting and underreacting. And you don’t want politics to influence these decisions.

Background

The swine influenza A (H1N1) virus that has infected humans in the United States, Mexico and elsewhere is a novel influenza A virus that has not previously caused illness in people. Not all details are known at this time, but CDC and HHS are currently investigating and taking appropriate actions to ensure the protection of port-based staff who may encounter ill individuals. Symptoms of swine flu are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have also reported diarrhea and vomiting associated with swine flu. On-going human-to-human transmission is occurring with confirmed cases identified in several states and counties.

Interim Recommendations

Recommendations in this guidance document are based on standard infection control and industrial hygiene practices and should be implemented immediately to protect workers and to delay the spread of this newly emerged influenza virus via airline travel. All airline personnel should follow the practices and instructions described below to prevent spreading infectious disease and becoming ill.

Hand Washing

Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol based hand cleaners are also effective. Avoid touching your eyes, nose or mouth because germs spread that way.

Cough Etiquette

Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

Stay Home From Work If You Are Sick

If you get sick, CDC recommends that you stay home from work and limit contact with others to keep from infecting them.

Management of Crew Exposure After Flight Completed

Flight deck and cabin crew members and ground personnel who may have been exposed to a passenger or worker suspected of having influenza should monitor their health for 7 days after the exposure. If they become ill with influenza-like symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea they should immediately take the following steps:

• Stay home except to seek medical care; do not report to work.
• Notify their employer.
• Contact their occupational health service or personal physician.
• Inform the occupational health service, clinic, or emergency room before visiting about the possible exposure to influenza.
• Do not travel, unless it is critical to travel locally for health care.
• Limit contact with others as much as possible.
• When not alone or in a public place, wear a facemask to reduce the number of droplets coughed or sneezed into the air.
• If traveling away from home, notify their employer and request assistance in locating a health care provider.
• If illness onset occurs while outside the United States, the airline’s medical consultants or overseas medical assistance companies should be contacted to assist finding an appropriate medical provider in that country.

For More Information

Interim Guidance for Airline Flight Crews and Persons Meeting Passengers Arriving from Areas With Avian Influenza http://wwwn.cdc.gov

The recent H1N1 pandemic has highlighted the importance of identifying public health measures which can help to mitigate flu virus transmission. Researchers conducted a prospective cluster-randomized trial to test whether improved hand hygiene or surgical face masks could reduce the spread of flu within households.

The researchers studied 407 people with flu-like symptoms who visited one of 45 outpatient clinics across Hong Kong within 48 hours of symptom onset, had rapid tests that confirmed infection with influenza A or B, and lived in a household with at least two other individuals, none of whom had reported flu symptoms in the preceding 14 days. The flu patients plus their household members were randomly assigned to one of three groups: control, control plus enhanced hand hygiene, and control plus enhanced hand hygiene plus face masks.

The researchers found that hand hygiene appeared to be effective at preventing household transmission of the flu virus only when implemented within 36 hours of symptom onset. These findings have important public health implications, as they suggest that non-pharmaceutical interventions can reduce flu transmission if implemented early after symptom onset.

Source:
Angela Collom
American College of Physicians