Infection prevention and control in health care for confirmed or suspected cases

Background
On 11 June 2009, WHO raised its pandemic alert level from phase 5 to phase 6 and characterized the outbreak of pandemic (H1N1) 2009 as moderate. Since the first recorded cases in April 2009, the virus has spread rapidly across the globe resulting in sustained community transmission in numerous countries and at least two WHO regions.
Health-care facilities (HCF) face the challenge of providing care for patients infected with the pandemic (H1N1) 2009 virus. It is critical that health-care workers (HCW), patients, and visitors follow the appropriate infection control (IC) precautions in order to minimize the possibility of transmission associated with health care.
IC measures for pandemic (H1N1) 2009 should be in harmony with other IC measures and strategies in health care. It is particularly important to acknowledge and quickly identify other respiratory diseases that may require different IC measures (e.g. pulmonary tuberculosis) and that have the potential for being overlooked due to large numbers of patients with respiratory symptoms.
Human-to-human transmission of the pandemic (H1N1) 2009 virus appears to be primarily through droplets. Therefore, IC precautions for patients with suspected or confirmed pandemic (H1N1) 2009 virus infection, as well as those with influenza-like symptoms or illnesses, should ensure control of the spread of respiratory droplets. The document “Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care - WHO Interim Guidelines”1 provides detailed information on infection prevention and control precautions for influenza virus with sustained human-to-human transmission applicable for the current pandemic (H1N1) 2009. This guidance note summarizes and highlights the main issues contained in the aforementioned document.
This document has been developed to meet the urgent need for guidance and the recommendations are only valid until new guidance becomes available, at the latest until the end of 2009.

Fundamentals of infection prevention strategies
Administrative controls are key components in infection prevention strategies and include implementation and facilitation of IC precautions; patient triage for early detection, patient placement and reporting; organization of services; policies on rational use of available supplies; policies on patient procedures; and strengthening of IC infrastructure.
Environmental/engineering controls, such as basic HCF infrastructure,2 adequate environmental ventilation, proper patient placement and adequate environmental cleaning can help reduce the spread of some pathogens during health care.
Rational use of available personal protective equipment (PPE) and appropriate hand hygiene also help reduce spread of infection.
1 Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care WHO Interim Guidelines. WHO, 2007. Available at http://www.who.int/csr/resources/publications/WHO_CD_EPR_2007_6/en/index.html.
2 Essential environmental health standards in health care. WHO, 2008. Available at http://whqlibdoc.who.int/publications/2008/9789241547239_eng.pdf.

3 WHO Guidelines on Hand Hygiene in Health Care. WHO 2009. Available at http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf.
4 Standard Precautions: Basic precautions designed to minimize direct, unprotected exposure to potentially infected blood, body fluids or secretions applicable to all patients. Available at www.who.int/csr/resources/publications/standardprecautions/en/index.html.
5 PPE for Droplet Precautions: Health-care workers to wear medical mask if working within approximately 1 meter of the patient.
6 Groups at high risk: Infants and young children <5>65 years), nursing home residents, pregnant women, and patients with co-morbid conditions such as cardiovascular, respiratory or liver disease, diabetes, and those with immunosuppression related to malignancy, HIV infection or other diseases.
7 Details on the correct use of PPE are available at: http://www.who.int/csr/resources/publications/WHO_CD_EPR_2007_6/en/index.html
Critical infection control measures
Several measures are recommended in the context of pandemic (H1N1) 2009 and other epidemics. First, avoid crowding patients together (maintain a minimum distance of >1 metre between patients). Second, promote respiratory etiquette and hand hygiene by providing necessary supplies and training individuals in the proper use of medical masks and hand hygiene immediately after contact with respiratory secretions. Third, apply Standard4 and Droplet5 Precautions. Last, consider special arrangements for vulnerable groups at high risk6 for complications from pandemic (H1N1) 2009 viral infection.

Summary of infection control precautions in specific situations
1. Caring for patients with suspected or confirmed infection
For staff providing care for patients with suspected or confirmed pandemic (H1N1) 2009 infection and for patients with influenza-like symptoms, the following precautions should be taken.
1.1 When working in direct contact with patients, Standard and Droplet Precautions should always be applied.
As per Droplet Precautions:
• wear a medical mask, if working within or <>12 air changes per hour);
• avoid permitting unnecessary individuals into the room; and
• perform hand hygiene before and after patient contact, and after PPE removal.

8WHO Information for Laboratory Diagnosis of New Influenza A (H1N1)Virus in Humans. WHO, 2009. Available at http://www.who.int/csr/resources/publications/swineflu/diagnostic_recommendations/en/index.html.
Aspiration of the respiratory track may be associated with increased risk for disease transmission. Nasopharyngeal swabbing and the vigorous swabbing of tonsils for sample collection may trigger intense cough at very close distance to the person doing the procedure.
Clinical management of human infection with avian influenza A (H5N1) virus. WHO, 2007. Available at http://www.who.int/csr/disease/avian_influenza/guidelines/clinicalmanage07/en/index.html
PPE for Contact Precautions: Health-care workers should wear gowns and clean gloves when providing direct care.
IC recommendations for avian influenza in health-care facilities is available at: http://www.who.int/csr/disease/avian_influenza/guidelines/aidememoireinfcont/en/index.html .
2. Collection of laboratory specimens
Upper respiratory tract specimens are the most appropriate samples for laboratory testing of pandemic (H1N1) 2009 virus in humans. Samples should be taken from the deep nostrils (nasal swab), nasopharynx (nasopharyngeal swab), nasopharyngeal aspirate, and/or throat or bronchial aspirate. Blood samples may be used for serologic purposes (either during the acute or convalescent phases). In addition to Standard Precautions, specific IC precautions should be taken when collecting patient specimens as follows.
2.1 Nasal swab and nasal wash:
• use face protection (either a medical mask and eye-visor or goggles, or a face shield);
• wear a gown and clean gloves; and
• perform hand hygiene before and after patient contact, and immediately after removal of PPE.

2.2 Collection of nasopharyngeal aspirate, nasopharyngeal swab, throat swab or bronchial aspirate:
• follow the same precautions as for Aerosol generating procedures (above).

2.3 For the collection of blood:
• use a medical mask (if performed during the acute infectious phase);
• use clean gloves;
• perform hand hygiene before and after patient contact, and immediately after removal of PPE.

3. Infection control precautions for patient care in regions where both avian influenza A (H5N1) and pandemic (H1N1) 2009 have been reported Patients presenting with influenza-like illness (ILI) might be infected with different types of influenza virus (e.g. avian influenza A (H5N1) or pandemic (H1N1) 2009), as well as other respiratory pathogens. Epidemiological and clinical10 clues should be used in triage areas to identify and apply the appropriate infection prevention and control measures in accordance with the most likely diagnosis. Laboratory diagnosis should be pursued for etiological clarification. A laboratory confirmed diagnosis is not always available or might be delayed, but clinical clues and epidemiological link(s), such as contact with infected patients or animal exposures, can aid in the presumptive diagnosis of avian influenza A (H5N1) and pandemic (H1N1) 2009. For laboratory confirmed or suspect cases of avian influenza A (H5N1) infection, Standard plus Droplet plus ontact11 Precautions and eye protection should be applied when providing routine care.

KEY ELEMENTS FOR INFECTION PREVENTION IN HEALTH CARE

1. Basic infection control recommendations for all health-care facilities Standard and Droplet Precautions should be used when caring for a patient with an acute, febrile, respiratory illness.
2. Respiratory hygiene/cough etiquette Health-care workers, patients and family members should cover their mouth and nose with a
3 Interim WHO guidance for the surveillance of human infection with swine influenza A (H1N1) virus. WHO, 2009. Available at: http://www.who.int/csr/disease/swineflu/WHO_case_definition_swine_flu_2009_04_29.pdf
4 Mothers and newborn infants should be kept together unless absolutely necessary. The benefits of not separating a mother and her newborn baby and of breastfeeding outweigh the potential risks.
5 Laboratory Biosafety Manual - Third Edition. WHO, 2004. Available at: http://www.who.int/csr/resources/publications/biosafety/WHO_CDS_CSR_LYO_2004_11/en/index.html.
disposable tissue when coughing, then discard the tissue in a receptacle and perform hand hygiene afterwards.
6.Triage, early recognition and reporting of pandemic (H1N1) infection Consider assessing pandemic (H1N1) 2009 virus infection in patients with acute, febrile, respiratory illness in places where community-level spread is occurring or in patients who have been in an affected region within one week prior to symptom onset and who have been exposed to pandemic (H1N1) 2009 by an infected patient.13
7. Placement of suspected and confirmed pandemic (H1N1) 2009 infected patients Place patients with the same diagnosis in wards keeping at least 1 metre distance between beds.14 All persons entering the isolation area should adhere to Standard and Droplet Precautions. For health services targeting healthy populations, such as pregnant women, children attending immunization services or regular check-ups, measures must be taken to avoid exposing healthy people to suspected or confirmed cases.
8. Additional measures to reduce pandemic (H1N1) 2009 virus transmission associated with health care Limit the number of health-care workers/family members/visitors exposed to the pandemic (H1N1) 2009 patient. Implement rooming-in policies to keep mothers and babies together.
9. Specimen transport/handling within health-care facilities Follow applicable transport regulations and requirements and use Standard Precautions for specimen transport to the laboratory. Health-care facility laboratories should follow good biosafety practices.15
10. Family member/visitor recommendations Family members/visitors should be limited to those essential for patient support and should use the same IC precautions as health-care workers.
11. Patient transport within health-care facilities Suspected or confirmed pandemic (H1N1) 2009 patients should wear a medical mask or cover their cough and practice appropriate hand hygiene while being transported within health-care facilities.
12. Pre-hospital care (e.g. transportation to hospital). When transporting patients to hospital, IC precautions are similar to those practiced during hospital care for all involved in the care of suspected pandemic (H1N1) 2009 patients.
13. Occupational health Monitor health of health-care workers exposed to pandemic (H1N1) 2009 patients. Health-care workers with symptoms should stay at home. Vulnerable groups at high risk for complications of pandemic (H1N1) 2009 infection should carefully follow recommended infection-control measures. In addition, alternatives such as reassignment to other duties should be considered. Antiviral prophylaxis should follow local policy.
14. Waste disposal Standard Precautions should be used when handling and disposing of sharps and contaminated items.
15. Dishes/eating utensils Wash using routine procedures with water and detergent. Use non-sterile rubber gloves.
16. Linen and laundry Wash with routine procedures, water and usual detergent; avoid shaking linen/laundry during handling before washing. Wear non-sterile rubber gloves.
17. Environmental cleaning Ensure that appropriate and regular cleaning is performed with water and usual detergent on soiled and/or frequently touched surfaces (e.g. door handles).
18. Patient care equipment Ensure cleaning and disinfection of reusable equipment between patients. ²

19. Duration of pandemic (H1N1) 2009 infection control precautions Until further information becomes available, IC precautions should be practiced for seven days from the onset of symptoms. For prolonged illness with complications (i.e. pneumonia), control measures should be used during the duration of acute illness. Children may shed the virus longer than adults, and personal hygiene and separation from immunologically naive family members is recommended for at least one week after the resolution of fever.
20. Patient discharge If the pandemic (H1N1) 2009 patient is still infectious upon hospital discharge (i.e. discharged within the period of IC precautions: see 16 above), instruct family members on appropriate IC precautions in the home.
21. Prioritization of PPE when supplies are limited Medical masks and hand hygiene supplies should be prioritized for the care of all pandemic (H1N1) 2009 patients.
22. Health-care facility (HCF) engineering controls The HCF spaces should be well ventilated. Aerosol-generating procedures should be performed in adequately-ventilated rooms (>12 air changes per hour).
23. Mortuary care Mortuary staff and the burial team should apply Standard Precautions, i.e. perform proper hand hygiene and use appropriate PPE according to the risk of exposure to body fluids (e.g. gown, gloves, and facial protection if there is a risk of splashes from patient's body fluids/secretions onto staff member's body and face).
24. Health-care facility managerial activities Development of procedures to ensure proper implementation of administrative controls, environmental controls and use of PPE, including adequate staffing and supplies, training of staff, education of patients and visitors and a strategy for risk communication.
25. Health care in the community Limit contact with the person with influenza-like symptoms as much as possible. If close contact is unavoidable, use the best available protection against respiratory droplets and perform hand hygiene.

Laboratory-confirmed cases of pandemic (H1N1) 2009 as officially reported to WHO by States Parties to the IHR (2005) as of 6 August 2009

EPIDEMOLOGY OF SWINE FLU

Qualitative indicators (as of Week 30: 20 July - 26 July 2009 and Week 31: 27 July - 2 August 2009)

As a part of WHO ongoing efforts to monitor the pandemic, qualitative indicators were developed to accommodate several types of data sources. Using these indicators, countries at different stages of the pandemic can participate in the monitoring effort, regardless of their surveillance and laboratory capacity. The qualitative indicators monitor: the global geographic spread of influenza, trends in acute respiratory diseases, the intensity of respiratory disease activity, and the impact of the pandemic on health-care services.
Interim WHO guidance for the surveillance of human infection with A(H1N1) virus
A description of WHO pandemic monitoring and surveillance objectives and methods can be found in the updated interim WHO guidance for the surveillance of human infection with pandemic (H1N1) virus.
The attached maps display information on the qualitative indicators reported for weeks 30 and 31. Information is available for approximately 50 to 60 countries each week. Implementation of this monitoring system is ongoing and completeness of reporting is expected to increase over time.

Epidemiological Update on the Global Situation

Pandemic influenza H1N1 has now been reported in over 170 countries and territories worldwide. While the case counts no longer reflect actual disease activity, WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and member states. Of particular interest is the situation in temperate countries of the Southern Hemisphere, which are now passing through their winter season. This season, pandemic H1N1 has been the predominant influenza virus in nearly all of the temperate regions of Southern Hemisphere, with South Africa being a notable exception. Australia and countries in the southern part of South America experienced rapid increases in cases of pandemic influenza early in their winter season. These same areas are now starting to report decreases in the numbers of people seeking care and being admitted to hospital. Although the virus is still circulating in these areas as it moves into areas not affected earlier, the overall national trends are downward. South Africa, in contrast, experienced an early influenza season with a seasonal subtype, influenza A (H3N2). As the influenza season in South Africa reached its peak in early to mid June and began to decline, pandemic influenza H1N1 appeared and has now become the dominant subtype seen there as well. In the temperate areas of the northern hemisphere which experienced early outbreaks of pandemic H1N1 influenza, including countries in North America and Europe, the virus continues to spread to new areas and cause intense local outbreaks. However, the overall national trend in cases is downward in the Americas. Tropical regions of the world, which typically experience year round transmission of influenza viruses with peak transmission at different and often multiple times in a year, are now seeing increases in cases, for example in tropical areas of Central and South America and in South and South East Asia. In summary, the overall picture of transmission globally is one of declining transmission in the temperate regions of the Southern Hemisphere with the exception of southern Africa. The season in these areas was characterized by rapid rise and fall of respiratory disease numbers, as is seen in a normal influenza season. The impact and severity of the season in these areas in terms of proportion of cases which developed severe disease and the load imposed on health care infrastructure is still being evaluated but generally appeared slightly worse than a normal influenza season in most places with increased hospitalization requiring respiratory critical care. The northern hemisphere is experiencing continued spread of the virus but declining activity is being observed in areas affected early in the course of the pandemic. Tropical areas of the world are now experiencing increasing numbers of cases at a time when the usual seasonal peaks would occur. As the pandemic H1N1 influenza virus is now the dominant strain in most areas of the world, it can be expected to persist into the coming influenza season in the Northern Hemisphere. Additionally, there is a risk of further spread of virus in highly populated areas as community spread starts occurring in Asia and Africa.

Pandemic influenza in pregnant women

Pandemic (H1N1) 2009
Research conducted in the USA and published 29 July in The Lancet [1] has drawn attention to an increased risk of severe or fatal illness in pregnant women when infected with the H1N1 pandemic virus.
Several other countries experiencing widespread transmission of the pandemic virus have similarly reported an increased risk in pregnant women, particularly during the second and third trimesters of pregnancy. An increased risk of fetal death or spontaneous abortions in infected women has also been reported.

Increased risk for pregnant women
Evidence from previous pandemics further supports the conclusion that pregnant women are at heightened risk.
While pregnant women are also at increased risk during epidemics of seasonal influenza, the risk takes on added importance in the current pandemic, which continues to affect a younger age group than that seen during seasonal epidemics.
WHO strongly recommends that, in areas where infection with the H1N1 virus is widespread, pregnant women, and the clinicians treating them, be alert to symptoms of influenza-like illness.

WHO recommendations for treatment
Treatment with the antiviral drug oseltamivir should be administered as soon as possible after symptom onset. As the benefits of oseltamivir are greatest when administered within 48 hours after symptom onset, clinicians should initiate treatment immediately and not wait for the results of laboratory tests.
While treatment within 48 hours of symptom onset brings the greatest benefits, later initiation of treatment may also be beneficial. Clinical benefits associated with oseltamivir treatment include a reduced risk of pneumonia (one of the most frequently reported causes of death in infected people) and a reduced need for hospitalization.
WHO has further recommended that, when pandemic vaccines become available, health authorities should consider making pregnant women a priority group for immunization.

Danger signs in all patients
Worldwide, the majority of patients infected with the pandemic virus continue to experience mild symptoms and recover fully within a week, even in the absence of any medical treatment. Monitoring of viruses from multiple outbreaks has detected no evidence of change in the ability of the virus to spread or to cause severe illness.
In addition to the enhanced risk documented in pregnant women, groups at increased risk of severe or fatal illness include people with underlying medical conditions, most notably chronic lung disease (including asthma), cardiovascular disease, diabetes, and immunosuppression. Some preliminary studies suggest that obesity, and especially extreme obesity, may be a risk factor for more severe disease.
Within this largely reassuring picture, a small number of otherwise healthy people, usually under the age of 50 years, experience very rapid progression to severe and often fatal illness, characterized by severe pneumonia that destroys the lung tissue, and the failure of multiple organs. No factors that can predict this pattern of severe disease have yet been identified, though studies are under way.
Clinicians, patients, and those providing home-based care need to be alert to danger signs that can signal progression to more severe disease. As progression can be very rapid, medical attention should be sought when any of the following danger signs appear in a person with confirmed or suspected H1N1 infection:
shortness of breath, either during physical activity or while resting
difficulty in breathing
turning blue
bloody or coloured sputum
chest pain
altered mental status
high fever that persists beyond 3 days
low blood pressure.
In children, danger signs include fast or difficult breathing, lack of alertness, difficulty in waking up, and little or no desire to play.