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Flu Season is Over, Now What?

The 2018-2019 flu season has been a record breaker. According to the CDC, this flu season was the longest in a decade, clocking in at a whopping 21 weeks with at least 36 million cases of influenza reported. Although, this flu season is over, the risk of pandemic flu is always with us, as is the risk of other infectious diseases caused by unique pathogens such as SARS or Ebola.1

In Eastern Congo, currently there is an Ebola outbreak underway that is well into its eighth month and is rapidly becoming the worst in that country’s history with more than 1,200 cases.2 Meanwhile, in the United States, officials are reporting the highest number of measles cases in five years, with 22 states reporting outbreaks. In 2017, the World Health Organization reported almost 100 infectious disease outbreaks from flu to bubonic plague. 3

CDC National Update on the Measles Outbreak

On April 29th the CDC reported 704 cases of measles, the greatest number of cases reported in the U.S. since measles was eliminated. Measles is not a harmless childhood illness, but a dangerous, highly contagious disease. Most of us have never seen the deadly consequences that vaccine-preventable diseases can have on a child, family or community.8 The virus is transmitted by direct contact with infectious droplets or by airborne spread.

Because measles virus can remain infectious in the air for up to two hours after an infected person leaves the area, the CDC recommends that

  • Healthcare facilities should follow airborne precautions
  • All healthcare staff should use respiratory protection when entering a patient’s room: and N95 respirator or similar protection.9

PREPARING FOR SEASONAL AND PANDEMIC FLU

Seasonal flu, caused by influenza B and some influenza A viruses, is typically not severe in most people, because they are already partially protected by having had a similar flu virus before or an annual flu shot. Pandemic flu, on the other hand, occurs when a strain is so different from previous strains that few people, if any, are immune - enabling it to spread easily from person to person.1

Methods to limit transmission of both seasonal and pandemic flu include:7

  • Hand hygiene
  • Social distancing
  • Cough etiquette
  • Using personal protective equipment (PPE)

For healthcare facilities, preparing to handle both seasonal and pandemic flu as well as other types of infectious disease outbreaks, it’s important to consider what kind of PPE is needed. Protecting patients, hospital staff and visitors requires the availability and appropriate use of a range of PPE including:7

  • N95 respirators
  • Face masks
  • Gowns
  • Gloves

More Masks Free

KEY CONSIDERATIONS FOR SEASONAL FLU

Dealing with a seasonal flu outbreak requires specific precautions to prevent transmission. Wearing a surgical mask when entering a flu patient’s room prevents contact with large droplets generated when a patient coughs, sneezes, talks, or breathes. When performing tasks that might create splashes or otherwise put healthcare workers at risk of contamination, wear gloves, gowns, and eye protection. For aerosol-generating procedures such as endotracheal intubation and airway suction, use a respirator and goggles. At minimum, use a fit-tested N95 disposable respirator when performing an aerosol generating procedure, for maximum protection, use a full face shield in front of a respirator.2

Steps to ensure your facility has the requisite amount of PPE on hand for flu season:

  • Assess the exposure risks for each job role and task at your facility
  • Categorize the risks as very high, high, medium or low
  • Determine what mix of PPE is required for each task

Gowns, masks or respirators, face shields/goggles, gloves, etc., may be appropriate for some tasks but not others. In order to have an adequate supply of each type of PPE, you need to estimate the frequency of each task and procedure and estimate the number of employees who fall into each category. Doctors, nurses, patients, visitors, EMS, lab, transport, environmental services, etc. will each have different needs.2

KEY CONSIDERATIONS FOR PANDEMIC FLU

Healthcare personnel who work closely with people known or suspected to be infected with pandemic influenza (either in contact with or within 6 feet) should wear:

  • Respiratory protection (N95 or higher rated filter for most situations) for protection against small droplets from talking, coughing, sneezing and from small airborne particles of infectious material
  • Eye protection or face shields if splashes are anticipated
  • Medical/surgical gowns or other disposable/ decontaminable protective clothing
  • Gloves to reduce transfer of infectious materials

The types of PPE appropriate for pandemic flu are similar to seasonal flu, but the quantities required may be significantly different as the duration of the pandemic may be longer. OSHA suggests a community assume two waves of a pandemic, each 12 weeks long. In addition, in the case of a pandemic, more employees may be at high risk. Increased respiratory protection such as N95 respirators may be required in addition to isolation gowns, to protect from blood and bodily fluids. It’s also important to remember that vaccines may not be immediately available which will increase exposure risks and PPE needs. To estimate the amount of PPE you will need, consider:

  • The risk of exposure
  • What PPE is needed and how often
  • The number of employees who will require it2

KEY CONSIDERATIONS FOR UNIQUE PATHOGENS SUCH AS EBOLA2

The CDC has issued recommendations for facilities to increase PPE as part of Ebola preparedness planning. The guidance for state and local health departments, acute care hospitals, and other emergency care settings, including urgent care clinics, is for to use in estimating and attaining the minimum amount of PPE to have on hand. The department of Health and Human Services and CDC also keep in contact with manufacturers and distributors of medical equipment and supplies to maintain awareness of the availability of PPE.

The amount of PPE a facility needs depends on the facility’s role in an outbreak. State and local public health authorities and officials, are identifying acute healthcare facilities to serve in various roles. These roles are outlined in CDC’s Interim Guidance for U.S. Hospital Preparedness for Patients with Possible or Confirmed Ebola Virus Disease: A Framework for a Tiered Approach. The intent is to create a coordinated, comprehensive, and networked approach among healthcare facilities. As described in the guidance, the role a facility plays in identifying, isolating, evaluating, and in some facilities, treating patients under investigation (PUIs) for Ebola virus disease (EVD) determines the amount of PPE needed.

Frontline Hospitals2

Most U.S. acute care facilities equipped for emergency care are in the “frontline” tier and require PPE sufficient for 12-24 hours of care. State and local authorities monitor people who have had a recognized EVD exposure risk within the last 21 days. These people are directed to designated facilities for evaluation if they become ill, making it unlikely that patients with unrecognized EVD will seek treatment at a frontline healthcare facility without warning.

However, if a patient was to seek treatment without warning, he or she would likely have mild symptoms such as isolated fever and it is unlikely that a frontline healthcare facility would be required to provide care for more than 12 to 24 hours for a severely ill patient at high risk for EVD. Therefore, most patients can be cared for in these facilities using:

  • A face shield and a surgical face mask
  • A fluid-resistant disposable gown
  • 2 pairs of gloves with extendable cuffs

Planning for PPE in Frontline Hospitals

Planning for PPE supplies in frontline facilities should focus on ensuring an adequate amount of gloves, gowns, surgical facemasks, and face shields and ensuring that all staff are regularly trained on their use. They should also ensure that healthcare workers who may be required to use Ebola PPE are trained for their roles in Ebola patient care and have demonstrated proficiency in use of Ebola PPE, including donning and doffing.

Assessment Hospitals

Hospitals in the CDC’s "assessment" tier are those prepared to receive and isolate a PUI for EVD and care for the patient until a diagnosis can be confirmed or ruled out and until discharge or transfer is completed. These facilities should have Ebola PPE for at least 4 to 5 days of patient care. The initial isolation and evaluation of minimally symptomatic patients can be performed using PPE according to CDC’s Guidance for Emergency Department Evaluation and Management for Patients Who Present with Possible Ebola Virus Disease. These facilities should also be prepared to care for patients with more severe symptoms.

Planning for PPE in Assessment Hospitals

Assessment hospitals should be prepared to provide care for patients with possible EVD for up to 96 hours. The CDC recommends these facilities have sufficient Ebola PPE for at least 4 to 5 days of patient care. This takes into account the fact that it may take 72 hours or longer after symptom onset to definitively confirm or rule out a diagnosis.

Treatment Hospitals

Treatment hospitals are those prepared to care for patients with confirmed EVD throughout the course of their illness. These hospitals require Ebola PPE for at least 7 days. If hospitalization is anticipated to exceed 7 days, state and local health authorities, in collaboration with CDC, may provide or facilitate the procurement of additional PPE supplies. For managing patients with confirmed diagnoses who are clinically unstable, PPE recommendations include:

  • Impermeable gowns or coveralls (single-use) plus a disposable apron
  • A NIOSH-certified N95 respirator mask and full face shield or a PAPR covered with a disposable surgical hood
  • Boot covers and shoe covers
  • 2 pairs of exam gloves with extended cuffs

A Phased Approach to PPE Preparedness

Once you identify your facility’s role in the case of an EVD outbreak you can coordinate with state and local public health officials to see if centralized or shared inventories of product are available that you may access if needed. Some health departments may be aware of regional, state, or local stockpiles of Ebola PPE that may be available as some states have purchased supplies of PPE to backfill shortages within the hospital networks.2

The amount of PPE needed for each day of patient care varies depending on:

  • The number of patients
  • The acuity of patients
  • The projected number of staff
  • Healthcare team configuration
  • The length of shifts
  • The number of required breaks for staff wearing PPE
  • The location of the isolation unit
  • Staff support strategies
  • The waste management strategy
  • The location of the lab
  • The demand for lab testing
  • Hospital protocols for PPE

MANAGING YOUR PPE SUPPLIES

Keep your facilities supply of PPE in clean, secure environments with environmental controls, avoiding storage areas that are damp or have temperature extremes. When stocking items, keep a record of each product’s shelf life and storage conditions. Where possible, incorporate product rotation i.e., consume the oldest supplies first. And most important of all, ensure critical employees are trained and regularly practice proper PPE selection and donning and doffing procedures.5

KEEPING YOUR COMMUNITY SAFE

In addition, consider partnering with neighboring hospitals, in-network facilities, and/or healthcare coalitions to share inventory for limited supply products. Understand how quickly your suppliers can respond in an emergency or outbreak. Many PPE products are sourced from overseas and it may take weeks to ramp up and deliver critical additional supplies. Remember, ensuring the safety of healthcare personnel leads to better outcomes for everyone.2


REFERENCES

  1. CDC Website: https://www.cdc.gov/flu/weekly/
  2. CDC Website: https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/supplies.html
  3. Considerations for U.S Healthcare Facilities to Ensure Adequate Supplies of Personal Protective Equipment (PPE) for Ebola Preparedness
    https://www.cdc.gov/measles/cases-outbreaks.html
  4. https://www.cdc.gov/media/releases/2019/s0322-ebola-congo.html
  5. OSHA Website: Proposed Guidance on Workplace Stockpiling of Respirators and Facemasks for Pandemic Influenza
    https://www.osha.gov/dsg/guidance/proposedGuidanceStockpilingRespirator.pdf
  6. OSHA Website: Frequently Asked Questions on Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers
    https://www.osha.gov/SLTC/pandemicinfluenza/pandemic_health.html
  7. CDC Website:Interim Guidance for the Use of Masks to Control Seasonal Influenza Virus Transmission
    https://www.cdc.gov/flu/professionals/infectioncontrol/maskguidance.htm


SIDEBAR REFERENCES:

8. https://www.cdc.gov/media/releases/2019/t0429-national-update-measles.html
9. https://www.cdc.gov/measles/hcp/#isolation