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The following definitions may be used to determine the
need to apply infection prevention and control measures.
Influenza-like Illness (ILI)
Influenza-like illness (ILI) is defined as: Acute onset
of respiratory illness with fever and cough or shortness
of breath with or without one or more of the following:
sore throat, arthralgia, myalgia, headache or fatigue. In
patients under 5 years of age or >65 years and older,
fever may not be prominent. In children under 5 years of
age, gastrointestinal symptoms may also be present. H1N1
is a type of ILI and may present with any of the above symptoms.
Severe Respiratory Illness (SRI)
Individuals with SRI have chest radiograph findings of pulmonary
infiltrates in addition to the screening criteria noted
above.
Other Unexplained Illness
In the setting of a community outbreak we recommend applying
infection prevention & control measures for patients
presenting with one of:
– Unexplained hypoxemia
– Airspace disease on CXR
– Unexplained sepsis / shock
– Exacerbation of underlying cardiac or lung disease
Institutional infection control measures should incorporate
the following:
1. Source Control
2. Accommodation
3. Contact Precautions
4. Droplet Precautions/Respiratory Precautions
A more detailed reference may be found in the Public
Health Agency of Canada (28 July 2009) web site.
Interim
Guidance: Infection prevention and control measures for
Health Care Workers in Acute Care Facilities
Prior to any patient interaction, all health care workers
(HCWs) have a responsibility to always assess the infectious
risk posed to themselves and to other patients, visitors,
and HCWs. This risk assessment is based on professional
judgment about the clinical situation and up-to-date information
on how the specific healthcare organization has designed
and implemented engineering and administrative controls,
along with the availability and use of Personal Protective
Equipment (PPE).
The PCRA tool can be accessed at The
Public Health Agency of Canada website.
2.1.1 Source Control
Source Control includes both Administrative [e.g. patient
flow] and Engineering [e.g. glass/acrylic glass partitions
in triage areas] means. The importance of applying administrative
and engineering controls as the first strategy in protecting
the HCW from exposure to infectious agents in the health
care setting cannot be overemphasized. Health care organizations
should complete assessments of each area of all of their
acute care facilities including physical settings (e.g.
single rooms, use of partitions, ability to establish 2
metre distance between ILI cases and others), the types
of patients seen, and the types of patient care activities
undertaken.
Based on these assessments, organizations need to determine
what administrative and engineering controls are needed.
This is especially important for patient care areas/settings
where patients appear for initial assessment/investigation
before a diagnosis of H1N1 has been made (e.g. Emergency
Departments, ambulatory clinics).
2.1.2 Accommodation for Suspect ILI cases
Patients who have suspected/probable/confirmed H1N1 should
be placed in single rooms in the ICU. The decision to develop
a H1N1 ward should be made in consultation with each hospital’s
infection control officer(s) and performed only for confirmed
H1N1 cases. Suitable signage indicating the need and type
of precautions required should be placed on the door to
these single rooms. Every effort should be made to ensure
that the privacy of the patient is protected.
If aerosol-generating procedures are underway, they should
be in a negative-pressure isolation room. If a negative
pressure room is not available, a portable HEPA unit may
be brought into the room.
Stopping precautions must be done only in consultation
with the hospital’s infection control officers.
2.1.2 Contact Precautions
Health care workers must where gloves when entering the
room of a suspected or proven ILI case. Gloves should be
removed just before leaving the room and disposed of in
a hands-free waste receptacle. Gowns should be worn as per
routine practices. When worn, gowns should be removed just
before leaving the room and disposed of in a hands-free
receptacle. Use alcohol based hand rubs or soap and water
after removing gown and gloves and after leaving the room.
2.1.3 Droplet Precautions/Respiratory Protection
All staff and physicians providing care for patients on
Droplet/Contact Precautions must wear the following protective
clothing: a fit tested N95 mask*, eye protection (goggles
or face shield; eye glasses alone are not adequate), gown,
and gloves. Appropriate signage is to be placed at the patient’s
bedside to alert staff to the necessary precautions.
*It is recommended that all HCW undergo proper fit testing
for H1N1 masks.
Re recognize that some organizations have not recommended
the use of N95 masks for the routine care of patients with
suspected or confirmed H1N1. Indeed a recent
study in the Lancet suggests that there is no
evidence for increased risk of H1N1 infection of HCW between
those that used routine surgical masks vs N95 masks. However
we feel that in the ICU there is risk for unanticipated
aerosolization of secretions (accidental ventilator disconnection,
suctioning). Consequently the CCCS working group recommends
that HCW wear fitted N95 masks when caring for intubated
patients with suspected or confirmed H1N1 infection or at
any time when procedures that are known to generate aerosols
(e.g. bronchoscopy, intubation) are being performed
When suctioning of intubated patients is required, closed
suctioning should be used.. Eye or face protection should
be removed after leaving the case’s room and disposed
of in either a hands-free waste receptacle (if disposable)
or in a separate receptacle to go for reprocessing (if reusable).
HCWs should perform hand hygiene before and after removing
the respiratory protection and after leaving the case’s
room.
2.1.5 Isolation
• In the setting of a community outbreak (as determined
by your regions public health authority we recommend the
isolation (using droplet precautions) of all patients presenting
with any one of
– Unexplained hypoxemia
– Airspace disease on CXR
– Unexplained sepsis / shock
– Unexplained exacerbation of underlying cardiac or
lung disease
• In the presence of a low level of community H1N1
activity (as determined and defined by your regions public
health authority) we recommend the isolation (using droplet
precautions) of all patients presenting with, any of recent
contact or travel to a high level region (it is recognized
that as the background level of H1N1 increases, contact
tracing will become irrelevant), new onset cough or fever
and one of
– Unexplained hypoxemia
– Airspace disease on CXR
– Unexplained sepsis / shock
– Exacerbation of underlying cardiac or lung disease
2.2 Discontinuing Isolation
Routine practices and additional precautions are to be
practiced in the intubated patient from symptom(s) onset
until:
– A patient, who presents with suspected H1N1, is
later proven to have a negative nasopharygeal and tracheal
aspirate by reverse transcriptase (RT)-PCR detection of
viral RNA or viral cell culture.
– An H1N1 positive patient, has 2 consecutive negative
nasopharygeal and tracheal aspirates performed 48 hours
apart by (RT)-PCR or viral cell culture.
– There is controversy about the duration of isolation
in a stable, afebrile patient who demonstrates persistent
viral shedding. At present we recommend that the decision
to remove isolation in this group of patients be discussed
on a case by case basis with infection control.
– Due to the potential for prolonged shedding in
critically-ill patients with H1N1, a paired NP swab and
ETA/BAL needs to be sent at day 7 and as otherwise described
above before stopping precautions
3.0 Diagnosis
Initial diagnostic testing is to be conducted in all patients
with suspected or probable H1N1. It is recognized that nasopharyngeal
(NP) swabs lack sufficient sensitivity to rule out H1N1
infection. Therefore initial diagnostic testing consists
of both deep nasopharyngeal swab (NP) AND endotracheal aspirate
(ETA)/ bronchoaveolar lavage (BAL) specimens for respiratory
viral detection. An endotracheal aspirate (or sputum if
not intubated) for gram stain and culture & sensitivity
should be sent as part of the initial testing to rule out
community acquired/hospital acquired pneumonia.
In a patient with an ILI we recommend the use of real-time
reverse transcriptase-polymerase chain reaction (rRT-PCR).
Details regarding the use of Rapid influenza diagnostic
testing and the proper procedure for specimen collection
may be found on the CDC web site.
Influenza
Diagnostic Tests (August 10, 2009)
Nasppharyngeal
Swab Proceedure
Due to the potential for prolonged shedding in critically-ill
patients with H1N1, a paired NP swab and ETA/BAL needs to
be sent at day 7 and as otherwise described above before
stopping precautions.
An ETA should be sent for repeat gram stain and culture
& sensitivity.
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