Abhay Chowdhary
Haffkine Institute, Parel, Mumbai
Address for Correspondence: Prof Abhay Chowdhary (MD, DHA, DM Virology, FIMSA), Director, Haffkine Institute, Parel, Mumbai 400012. Email: abhaychowdhary@yahoo.com ; haffkineinstitute@gmail.com
Prevention of the transmission
To prevent the transmission of
all respiratory infections in healthcare settings, including novel H1N1, respiratory hygiene/cough etiquette infection control measures should be implemented at the first point of contact with a potentially infected person. They should be incorporated into infection control practices as one component of Standard Precautions.
Clinical facilities should establish mechanisms to screen patients for signs and symptoms of febrile respiratory illness at any point of entry to the facility. Provisions should be made to allow for prompt isolation and assessment of symptomatic patients.
The current situation with novel H1N1 flu in the world is evolving quickly. Staff in healthcare settings should
monitor the H1N1 Flu website and National, state and local health department websites for the latest information. Healthcare facilities should review and make plans to implement their facility contingency response and/or pandemic response plans. This should include making plans for managing increasing patient volume and potential staffing limitations.
Infection Control Recommendations
If the patient is presenting in a community where novel H1N1 transmission is occurring (based upon information provided by state and local health departments), these infection control recommendations should apply to all patients with febrile respiratory illness (defined as fever [greater than 37.8° C] plus one or more of the following: rhinorrhea or nasal congestion; sore throat; cough).
If the patient is presenting in a community without novel H1N1 transmission, these infection control recommendations should apply to those patients with febrile respiratory illness AND:
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Close contact with a person who is a confirmed, probable, or suspected case of novel H1N1 virus infection, within the past 7 days OR |
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Travel to a community either within the United States or internationally where there are one or more confirmed novel H1N1 cases within 7 days |
As the situation evolves, the ability to use epidemiologic links to identify potentially infectious patients may be lost and these recommendations may need to be applied to all patients with febrile respiratory illness. This situation will be monitored, and these guidelines will be updated as needed.
Infection Control of Ill Persons in a Healthcare Setting
Screening of patients presenting to medical facility would be done in a location with negative pressure air handling whenever feasible.
Patient placement and transport
Any patients who have a confirmed, probable, or suspected case of novel H1N1 and present for care at a healthcare facility should be placed directly into individual rooms and the door should be kept closed. Healthcare personnel who interact with the patients should follow the infection control guidelines. For the purposes of this guidance, healthcare personnel are defined as persons, including employees, students, contractors, attending clinicians, and volunteers, whose activities involve contact with patients in a healthcare or laboratory setting.
For procedures that are likely to generate aerosols (e.g., bronchoscopy,
elective intubation, suctioning, administering nebulized medications),
an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. Facilities should monitor and document the proper negative-pressure function of AIIRs, including those in operating rooms, intensive care units, emergency departments, and procedure rooms.
Procedures for transport of patients in isolation precautions should be followed. Facilities should also ensure that plans are in place to communicate information about suspected cases that are transferred to other departments in the facility (e.g., radiology, laboratory) and other facilities. The
ill person should wear a surgical mask to contain secretions when outside of the patient room and should be encouraged to perform hand hygiene frequently and follow
respiratory hygiene/cough etiquette practices.
Limitation of healthcare personnel entering the isolation room
Healthcare personnel entering the room of a patient in isolation should be limited to those performing direct patient care.
Isolation precautions
All healthcare personnel who enter the patient’s room should take
standard and contact precautions plus eye protection should be used for all patient care activities for patients being evaluated or in isolation for novel H1N1. Maintain adherence to
hand hygiene by washing with soap and water or using alcohol-based hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions. Nonsterile gloves and gowns along with eye protection should be donned when entering a patient’s room. (See
Personal Protective Equipment (PPE) in Healthcare Settings)
Respiratory protection: All healthcare personnel who enter the rooms of patients in isolation with confirmed, suspected, or probable novel H1N1 influenza should wear a fit-tested disposable N95 respirator or better. Respiratory protection should be donned when entering a patient’s room.
Note that this recommendation differs from current infection control guidance for seasonal influenza, which recommends that healthcare personnel wear surgical masks for patient care. The rationale for the use of respiratory protection is that a more conservative approach is needed until more is known about the specific transmission characteristics of this new virus.
Management of visitors
Limit visitors for patients in isolation for novel H1N1 infection to persons who are necessary for the patient's emotional well-being and care. Visitors who have been in contact with the patient before and during hospitalization are a possible source of novel H1N1. Therefore, schedule and control visits to allow for appropriate screening for acute respiratory illness before entering the hospital and appropriate instruction on use of personal protective equipment and other precautions (e.g., hand hygiene, limiting surfaces touched) while in the patient's room. Visitors should be instructed to limit their movement within the facility.
Visitors may be offered a gown, gloves, eye protection, and respiratory protection (i.e., N95 respirator) and should be instructed by healthcare personnel on their use before entering the patient’s room.
Duration of precautions
Isolation precautions should be continued for 7 days from symptom onset or until the resolution of symptoms, whichever is longer.
Persons with novel H1N1 virus infection should be considered potentially contagious from
one day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might be contagious for longer periods.
Surveillance of healthcare personnel
In communities where novel H1N1 virus transmission is occurring, healthcare personnel should be monitored daily for signs and symptoms of febrile respiratory illness. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
In communities without novel H1N1 virus transmission, healthcare personnel working in areas of a facility where there are patients being assessed or isolated for novel H1N1 infection should be monitored daily for signs and symptoms of febrile respiratory infection. This would include healthcare personnel exposed to patients in an outpatient setting or the emergency department. Healthcare personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
Healthcare personnel who do not have a febrile respiratory illness may continue to work. Asymptomatic healthcare personnel who have had an unprotected exposure to novel H1N1 also may continue to work if they are started on antiviral prophylaxis.
Management of ill healthcare personnel
Healthcare personnel should not report to work if they have a febrile respiratory illness.
In communities where novel H1N1 transmission is occurring, healthcare personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities without novel H1N1 transmission, healthcare personnel who develop a febrile respiratory illness and have been working in areas of the hospital where swine influenza patients are present should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities where novel H1N1 transmission is not occurring, healthcare personnel who develop febrile respiratory illness and have not been in areas of the facility where swine influenza patients are present should follow facility guidelines on returning to work.
Personal protective equipment (PPE) and antiviral drugs
Facilities should implement plans to ensure appropriate allocation of personal protective equipment, including N95 respirators, and antiviral medications.
Environmental infection control Guideline for Environmental Infection Control in Health-Care Facilities, 2003
Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. Management of laundry, utensils and medical waste should also be performed in accordance with procedures followed for seasonal influenza. (See
Guideline for Environmental Infection Control in Health-Care Facilities, 2003. )
Facility access control
Facilities should have signage at entry points instructing patients and visitors about hospital policies, including the need to notify staff immediately if they have signs and symptoms of febrile respiratory illness. Facilities in communities where swine influenza transmission is occurring should limit points of entry to the facility.
Seasonal influenza vaccine
It is not anticipated that the seasonal influenza vaccine will provide protection against the novel H1N1 viruses. However, in the country, seasonal influenza viruses are circulating. Influenza vaccination is effective against these seasonal viruses and should continue to be given to unvaccinated patients in areas where seasonal influenza cases are still occurring.
*Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Staff should be medically cleared, fit-tested, and trained for respirator use, including: proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use. (See
Respiratory protection and fit test procedures).
Additional information on N95 respirators and other types of respirators: