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05-07-2009, 06:39 AM

This will be my last wall of words on this topic. See below from my work:

Updated DOHMH Infection Control Recommendations
for Influenza H1N1 (Swine-Origin)

The New York City Department of Health and Mental Hygiene (DOHMH) has been conducting intensive active surveillance for Influenza H1N1 (Swine-Origin) (SO) in New York City since April 24, and has prioritized the identification of any cases of severe illness due to this virus. Due to accumulating evidence that H1N1 (SO) virus is comparable to seasonal influenza in its spectrum of illness and transmission pattern, and does NOT appear to be causing unusual morbidity or mortality compared to seasonal influenza, DOHMH is now recommending that infection control measures for this virus be similar to those taken for seasonal influenza.

Since H1N1 ( SO) is a novel virus, its clinical and epidemiologic features are only now being elucidated, and these recommendations are therefore still subject to change. Also, there is no effective vaccine and we must assume that much if not all of the population is susceptible to the virus. It is also possible that this virus may become more virulent in the future, in which case these recommendations would need to be revised.

Although recommended infection control precautions are now similar to those recommended for seasonal influenza, DOHMH emphasizes that meticulous standard respiratory hygiene and cough etiquette should be practiced in all medical facilities. This includes the placement of a surgical facemask on all patients with influenza-like illness in all outpatient settings, in order to reduce the spread of the virus to health care workers and patients. Note that these infection control recommendations apply to ALL patients in New York City with influenza, including confirmed or probable H1N1 (SO), or with influenza-like illness.

The DOHMH recommends the following modifications to the interim infection control guidance previously provided for Influenza H1N1 (SO):

Inpatient Settings and Hospital Emergency Departments
• Continue to advise patients with fever and acute respiratory symptoms, such as cough or sore throat, to notify the triage nurse immediately. Patients with these complaints should be placed in a single room with closed door if possible, or asked to wait at least 3-6 feet away from other people. The patient should be asked to wear a surgical mask as tolerated and to perform hand hygiene.
• Use STANDARD and DROPLET precautions for routine medical care of patients with confirmed or probable H1N1 influenza, or influenza-like illness (case definitions given at the end of this document). Negative pressure AIIR’s and N95 respirators are no longer recommended for routine patient care for patients with H1N1 influenza or influenza-like illness.
• Aerosol-generating procedures (e.g., bronchoscopy, intubation and extubation, and deep open tracheal suctioning) should be performed, when feasible, in a negative pressure airborne infection isolation room (AIIR). Disposable fit-tested N95 respirators and eye protection (goggles or face shield) should be worn by health care personnel performing these procedures.
• The patient should be placed in a private room for medical care whenever possible.
• When being transferred from the emergency room to the inpatient room, and at all times while hospitalized, the patient should wear a surgical facemask when outside the room.
• Health care workers examining, caring for or obtaining nasal, nasopharyngeal or pharyngeal specimens from patients with probable or confirmed swine influenza should wear a surgical facemask.
• Note that if tuberculosis is being considered, the patient should be placed in an AIIR and staff entering the room should wear a fit-tested N95 respirator.
• Hand hygiene is absolutely essential, and should be performed before and after patient care, and before donning and after removal of a surgical facemask. Fit-tested N95 masks and eye protection (goggles) are not necessary, except for aerosol-generating procedures as described above.
• Nebulization treatments for patients with febrile respiratory illness should be provided in a private room with closed door if at all possible, 6 feet apart at a minimum if a private room is not available. If private rooms are limited, reserve the private rooms for patients with febrile respiratory disease. If no private room is available, use a curtain or other barrier between patients who are in the same room when performing nebulization treatments.
• Visitors should be asked to perform hand hygiene before entering and after exiting the patient’s room, and advised to wear a surgical facemask while in the ro om with the patient.

In Clinics, Medical Offices or other Ambulatory Care Settings
• Patients with influenza-like illness in outpatient settings should be asked to wear a surgical mask, as tolerated, while being examined and cared for.
• Staff who have close contact, including examining or providing direct medical care for the patient with febrile respiratory illness, should wear a surgical facemask and gloves, and should ideally put the mask on before entering the room.
• Staff should be instructed to perform hand hygiene, put facemask on first followed by gloves, then when patient care is complete, remove gloves first then facemask, and perform hand hygiene.
• If a nasopharyngeal swab or other respiratory specimen is being collected, the patient should be instructed to remove the facemask briefly for specimen collection, then replace the mask as soon as the specimen is obtained.
• Meticulous hand hygiene should be performed before and af ter removal of PPE and before and after patient care.

All staff working in hospital, medical or office settings should be instructed NOT to work if they are ill. If they become ill while working, they should be instructed to go home immediately and follow the facility’s employee health policies. While waiting to go home, they should be asked to wear a surgical facemask and to sit away from other staff and patients.

These recommendations have been reviewed with, and are consistent with forthcoming guidance from the New York State Department of Health.

Refer to Health Alerts # 13-15 for current reporting requirements, laboratory diagnostic testing guidance, antiviral treatment and prophylaxis recommendations. All guidance is likely to change as the situation evolves and will be forwarded when available. Please check the New York City Department of Health and Mental Hygiene website at www.nyc.gov/health for updated guidance (see Information for P roviders).

NYC DOHMH Case Definitions (as of 5/6/2009):

A confirmed case of H1N1 (SO) infection is defined as a person with influenza-like illness with laboratory confirmed H1N1 (SO) infection by one or more of the following tests:
• real-time RT-PCR, or
• viral culture (currently only performed at CDC).

A probable case of H1N1 (SO) infection is defined as a person with an influenza-like illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR.

Influenza-like illness is defined as fever>100.4◦ F or 38.0 C◦ AND cough or sore throat.

Standard Precautions Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients. These include: hand hygiene; use of gloves, gow n, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. The application of Standard Precautions during patient care is determined by the nature of the healthcare worker-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g., performing venipuncture), only gloves may be needed; during other interactions (e.g., intubation), use of gloves, gown, and face shield or mask and goggles is necessary.

Droplet Precautions Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Use Droplet Precautions as recommended in HICPAC/CDC Isolation Guideline found on the CDC website: http://www.cdc.gov/ncidod/dhqp/gl_isolation.html for patients known or suspected to be infected with pathogens transmitted by respiratory droplets (i.e., large-particle droplets >5µ in siz e) that are generated by a patient who is coughing, sneezing or talking. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. A single patient room is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of > 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route. Healthcare personnel wear a mask (a respirator is not necessary) for close contact with infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of th e room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.

05-07-2009, 06:39 AM	#128
Drat Guest Posts: n/a	Re: Lets talk about the Swine flu... This will be my last wall of words on this topic. See below from my work: Updated DOHMH Infection Control Recommendations for Influenza H1N1 (Swine-Origin) The New York City Department of Health and Mental Hygiene (DOHMH) has been conducting intensive active surveillance for Influenza H1N1 (Swine-Origin) (SO) in New York City since April 24, and has prioritized the identification of any cases of severe illness due to this virus. Due to accumulating evidence that H1N1 (SO) virus is comparable to seasonal influenza in its spectrum of illness and transmission pattern, and does NOT appear to be causing unusual morbidity or mortality compared to seasonal influenza, DOHMH is now recommending that infection control measures for this virus be similar to those taken for seasonal influenza. Since H1N1 ( SO) is a novel virus, its clinical and epidemiologic features are only now being elucidated, and these recommendations are therefore still subject to change. Also, there is no effective vaccine and we must assume that much if not all of the population is susceptible to the virus. It is also possible that this virus may become more virulent in the future, in which case these recommendations would need to be revised. Although recommended infection control precautions are now similar to those recommended for seasonal influenza, DOHMH emphasizes that meticulous standard respiratory hygiene and cough etiquette should be practiced in all medical facilities. This includes the placement of a surgical facemask on all patients with influenza-like illness in all outpatient settings, in order to reduce the spread of the virus to health care workers and patients. Note that these infection control recommendations apply to ALL patients in New York City with influenza, including confirmed or probable H1N1 (SO), or with influenza-like illness. The DOHMH recommends the following modifications to the interim infection control guidance previously provided for Influenza H1N1 (SO): Inpatient Settings and Hospital Emergency Departments • Continue to advise patients with fever and acute respiratory symptoms, such as cough or sore throat, to notify the triage nurse immediately. Patients with these complaints should be placed in a single room with closed door if possible, or asked to wait at least 3-6 feet away from other people. The patient should be asked to wear a surgical mask as tolerated and to perform hand hygiene. • Use STANDARD and DROPLET precautions for routine medical care of patients with confirmed or probable H1N1 influenza, or influenza-like illness (case definitions given at the end of this document). Negative pressure AIIR’s and N95 respirators are no longer recommended for routine patient care for patients with H1N1 influenza or influenza-like illness. • Aerosol-generating procedures (e.g., bronchoscopy, intubation and extubation, and deep open tracheal suctioning) should be performed, when feasible, in a negative pressure airborne infection isolation room (AIIR). Disposable fit-tested N95 respirators and eye protection (goggles or face shield) should be worn by health care personnel performing these procedures. • The patient should be placed in a private room for medical care whenever possible. • When being transferred from the emergency room to the inpatient room, and at all times while hospitalized, the patient should wear a surgical facemask when outside the room. • Health care workers examining, caring for or obtaining nasal, nasopharyngeal or pharyngeal specimens from patients with probable or confirmed swine influenza should wear a surgical facemask. • Note that if tuberculosis is being considered, the patient should be placed in an AIIR and staff entering the room should wear a fit-tested N95 respirator. • Hand hygiene is absolutely essential, and should be performed before and after patient care, and before donning and after removal of a surgical facemask. Fit-tested N95 masks and eye protection (goggles) are not necessary, except for aerosol-generating procedures as described above. • Nebulization treatments for patients with febrile respiratory illness should be provided in a private room with closed door if at all possible, 6 feet apart at a minimum if a private room is not available. If private rooms are limited, reserve the private rooms for patients with febrile respiratory disease. If no private room is available, use a curtain or other barrier between patients who are in the same room when performing nebulization treatments. • Visitors should be asked to perform hand hygiene before entering and after exiting the patient’s room, and advised to wear a surgical facemask while in the ro om with the patient. In Clinics, Medical Offices or other Ambulatory Care Settings • Patients with influenza-like illness in outpatient settings should be asked to wear a surgical mask, as tolerated, while being examined and cared for. • Staff who have close contact, including examining or providing direct medical care for the patient with febrile respiratory illness, should wear a surgical facemask and gloves, and should ideally put the mask on before entering the room. • Staff should be instructed to perform hand hygiene, put facemask on first followed by gloves, then when patient care is complete, remove gloves first then facemask, and perform hand hygiene. • If a nasopharyngeal swab or other respiratory specimen is being collected, the patient should be instructed to remove the facemask briefly for specimen collection, then replace the mask as soon as the specimen is obtained. • Meticulous hand hygiene should be performed before and af ter removal of PPE and before and after patient care. All staff working in hospital, medical or office settings should be instructed NOT to work if they are ill. If they become ill while working, they should be instructed to go home immediately and follow the facility’s employee health policies. While waiting to go home, they should be asked to wear a surgical facemask and to sit away from other staff and patients. These recommendations have been reviewed with, and are consistent with forthcoming guidance from the New York State Department of Health. Refer to Health Alerts # 13-15 for current reporting requirements, laboratory diagnostic testing guidance, antiviral treatment and prophylaxis recommendations. All guidance is likely to change as the situation evolves and will be forwarded when available. Please check the New York City Department of Health and Mental Hygiene website at www.nyc.gov/health for updated guidance (see Information for P roviders). NYC DOHMH Case Definitions (as of 5/6/2009): A confirmed case of H1N1 (SO) infection is defined as a person with influenza-like illness with laboratory confirmed H1N1 (SO) infection by one or more of the following tests: • real-time RT-PCR, or • viral culture (currently only performed at CDC). A probable case of H1N1 (SO) infection is defined as a person with an influenza-like illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR. Influenza-like illness is defined as fever>100.4◦ F or 38.0 C◦ AND cough or sore throat. Standard Precautions Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients. These include: hand hygiene; use of gloves, gow n, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. The application of Standard Precautions during patient care is determined by the nature of the healthcare worker-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g., performing venipuncture), only gloves may be needed; during other interactions (e.g., intubation), use of gloves, gown, and face shield or mask and goggles is necessary. Droplet Precautions Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Use Droplet Precautions as recommended in HICPAC/CDC Isolation Guideline found on the CDC website: http://www.cdc.gov/ncidod/dhqp/gl_isolation.html for patients known or suspected to be infected with pathogens transmitted by respiratory droplets (i.e., large-particle droplets >5µ in siz e) that are generated by a patient who is coughing, sneezing or talking. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. A single patient room is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of > 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route. Healthcare personnel wear a mask (a respirator is not necessary) for close contact with infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of th e room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.