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Preparing for another wave of H1N1 influenza is the perfect opportunity to raise awareness of the importance of infection control, writes Judy Forest.

As we move into flu season, those working within the residential care sector must be prepared for possible outbreaks of pandemic influenza A H1N1 or “swine flu”.

Since the beginning of this year there have been almost 50 confirmed cases of swine flu in Australia. In 2009, there were 37,636 cases, including 191 associated deaths. Up until March 2010 there were 5003 hospitalisations and 682 ICU admissions associated with swine flu in Australia.

Previous pandemics have come in second and even third waves. With the current focus on a second wave of pandemic influenza during the coming winter months it is a timely reminder for us all to ensure our outbreak management plan is well organised.

Influenza of any strain is a highly contagious disease of the respiratory tract which spreads quickly amongst a community. It is spread by droplets from coughs or sneezes or by touching contaminated items or surfaces, then touching the eyes mouth or nose before washing hands.
Initial symptoms may be similar to those of other respiratory infections with symptoms developing rapidly, one to four days after infection. Symptoms include fever, chills, cough, muscle or joint pain, stuffy runny nose, headache and sore throat.

The elderly may also experience confusion, shortness of breath, loss of appetite or increase in symptoms of chronic obstructive airways disease. Individuals may be infectious for up to seven days after infection and may be infectious one to two days before symptoms appear. Secondary bacterial infections such as pneumonia, meningitis, sinus and ear infections can also occur.

Epidemic Influenza occurs every year in various communities as new strains of Influenza A and B evolve and cause high rates of illness and death. This could be the case with the new swine flu.

Aged care facilities are considered to be high risk environments due to advancing age of residents, the presence of chronic medical conditions and the close proximity of living conditions.

Pandemic influenza is the spread of new type of influenza virus such as swine flu to many parts of the world. Most people do not have immunity to the new virus and thus are susceptible to infection. Because of the large numbers of people affected, an influenza pandemic can overwhelm health and community resources.

Pandemics have a tendency to recur in second and third waves with age groups and geographical areas not affected initially, proving vulnerable during subsequent waves. Previous pandemics have occurred in 1918-1919 (“Spanish Flu”), 1957 -1958 (“Asian Flu”) and 1968-1969 (“Hong Kong Flu”).

If an outbreak of influenza is suspected it is imperative that immediate action is taken to prevent further transmission to residents and staff.

The following is seven important infection prevention and control measures when preparing for a pandemic.

Preparing for an influenza outbreak such as H1N1 is an opportunity to heighten awareness of the importance of infection prevention and control throughout any facility. It is important not to wait for a pandemic to occur before implementing prevention strategies.

In accordance with the requirement of the Department of Health and Ageing, each facility must designate an outbreak manager. This may be the CEO, operations manager, director of nursing, manager or designated infection control officer.

A written plan for management of an outbreak of infection including pandemic influenza should already be in place.

Employers must take all practicable steps to mitigate the risks and protect employees, especially those at high risk, such as health care personnel and support staff from pandemic influenza should it recur this year. Employers need to actively plan to cover their risks and the risks to their workers and the public. Consideration will need to be given to strategies for minimising the risks of infection transmission.

1. Vaccination
Protection against swine flu is included in the 2010 seasonal flu vaccine with supplies primarily targeted at risk groups, including pregnant women, Aboriginal and Torres Strait Islander people aged 15 to 64 years, people aged six months to 64 years with chronic medical conditions such as cardiac disease and respiratory conditions and people aged 65 years and over. Staff of aged and residential care facilities are strongly recommended to have annual seasonal flu vaccination.

Having staff vaccinated now, before the flu season starts, will allow an orderly vaccination program and avoid undue pressure on vaccination providers if staff vaccination is held off until winter or until there is a rise in cases.

The vaccine for the Australian 2010 influenza season contains three strains – the pandemic (H1N1) 2009 strain (A/California/7/2009), an H3N2 strain (A/Perth/16/2009) and a B strain (B/Brisbane/60/2008).

2. Outbreak kit
Each facility should have an outbreak kit, which would contain immediate, necessary supplies should an outbreak occur. Adequate supply of items required during an outbreak should be acquired and kept in this outbreak kit, to ensure the facility can be self sufficient for a period of time. This kit would include;

• Hand hygiene products (alcohol based hand rub - gels, rinses or foams)
• Personal protective equipment (gloves, impermeable, long sleeved gowns or aprons and appropriate masks)
• Additional cleaning supplies, chemicals and cleaning equipment
• Relevant documentation, including your outbreak management plan, fact sheets and posters, outbreak policies and notification and tracking forms
• A list of key contacts including management, department of health units, general practitioners and relatives

3. Personal hygiene
Now is the time to remind staff, residents or visitors who have symptoms of respiratory infection to practice cough etiquette and, if necessary, remain at home until all symptoms have passed.

4. Hand hygiene
Before an outbreak occurs, ensure an alcohol-based hand rub is located at the entrance to each facility, and encourage staff, visitors and residents to perform hand hygiene as they enter the facility and thus do not carry the bugs in with them.

During an outbreak of pandemic influenza, such as H1N1, an alcohol-based hand rub should be located within the room of each affected resident to ensure staff clean their hands after removing gloves and other protective apparel, before leaving the room and as the last task carried out before moving to new resident or task.

5. Protective apparel
Latest guidelines from the CDC recommend the use of surgical masks, rather than the N95 high filtration masks, for the care of residents with swine flu. Now is the time to ensure an adequate supply of masks is available on site together with supplies of impermeable gowns and gloves.

Remember that staff entering the room of any person with influenza must wear personal protective apparel of medical examination gloves, fluid repellant masks and impervious, long sleeved gown or apron. Gown must be donned first, then mask and finally gloves.

It is important that all personnel are educated now in the correct methods of donning and removing protective apparel. Incorrect handling and removal of protective apparel has been documented as transmitting disease during previous epidemics.

6. Cleaning and laundry
Influenza viruses may be able to live for up to two to three days on hard surfaces such as doorknobs, handrails, cups, utensils, telephones so the focus on maintenance of high standards of cleaning must not be ignored. During an influenza outbreak the frequency of cleaning will need to be increased. Additional scheduled cleaning will be necessary so planning for this scenario should be in place.

7. Ongoing infection control training 
Now is the time to provide a refresher education for all staff on best practice infection prevention and control. This training should include the practice of cough etiquette, hand hygiene, appropriate wearing, removal and disposal of protective apparel and the application of additional airborne, droplet and contact precautions, all of which are integral to the management of any influenza outbreak.
Remember, preparing for another wave of H1N1 influenza is the perfect opportunity to raise awareness of the importance of infection prevention and control.

Judy Forrest is an infection control consultant and principal of Bug Control Infection Control Advisory Service.

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