Updated: April 30, 2009
With the number of confirmed cases of H1N1 virus, commonly called swine flu, growing in North America, and cases now being confirmed in Europe, Israel and New Zealand, world health officials are expressing concern that the illness has "pandemic potential."
"The current situation regarding the outbreak of swine influenza A(H1N1) is evolving rapidly," the World Health Organization said on Monday in a prepared statement. According to the WHO on Wednesday, non-North American countries that reported laboratory-confirmed cases are as follows:
- Austria (1)
- Germany (3)
- Israel (2)
- New Zealand (3)
- Spain (4)
- United Kingdom (5)
The majority of the confirmed cases are in North America, with 26 being in Mexico,13 in Canada and91 in theU.S. as of Wednesday afternoon. According to the Centers for Disease Control and Prevention (CDC), the 91 U.S. cases are in the following states:
- 51in New York,
- 14 in Southern California,
- 16 in Texas -- including one death
- two in Dickinson County, Kansas;Massachusetts andMichigan
- one in Arizona,Indiana,Nevada andOhio
The CDC offers interim guidelines for health professionals dealing with swine flu but warns the situation is constantly evolving. The CDC recommends using the specific personal protective equipment (PPE) when interacting with or treating people who have been within about 6 feet of a person with a confirmed or suspected case of swine flu, a person with acute respiratory illness who has been in an area with confirmed cases of swine flu, and a person with acute respiratory illness who recently came in contact with an animal suspected of having swine flu. The CDC defines relevant acute respiratory illness as recent onset of at least two of the following flu-like symptoms: rhinorrhea or nasal congestion, sore throat and a cough with or without a fever.
"Do not jump on interim guidelines: They're interim; they will change," warns JEMS Editorial Board Member Katherine West, BSN, Med, CIC.Click here to read West's top 10 swine-flu recommendations for EMS providers.
The CDC has released its EMS and 9-1-1 Swine-Origin Influenza A (H1N1) Infection Guidance, which is available at:http://www.cdc.gov/swineflu/guidance_ems.htm.
EMS Guidelines in San Diego & New York
San Diego County was one of the first areas to have confirmed cases of H1N1. "From the prehospital perspective, the county has made modifications to clinical protocols -- primarily at the ALS level -- to protect providers and mitigate spread of the virus," says JEMS technical editor Travis Kusman, and the manager and public information officer for San Diego County Operations of American Medical Response (AMR).
According to the County of San Diego Emergency Medical Services Authority (EMSA) Swine Flu Training for EMS Providers, swine flu has two characteristics that allow it to become a pandemic. These are that it is a brand-new, or "novel" virus, and that it is transmitted from person to person. Signs and symptoms are similar to those of seasonal influenza, and the county defines persons with an influenza-like illness (ILI) as ones who have afever greater than 100-degrees Fahrenheit WITH a cough and sore throat.
The county states providers should begin their primary survey 6 feet away from the patient, ask if they have the above symptoms and ask if they have recently traveled to Mexico. If they suspect the patient to have an ILI, they should wear an N95 mask and other PPE.
Modifications to prehospital ALS care for ILI patients in San Diego County include
Minimizing suctioning of patients to only when necessary,
- Avoiding CPAP (since the exhalation port isn't filtered),
- Avoiding use of nebulizer treatments,
- Limiting intubations to only when bag-valve masks and ETAD are not possible or effective, and
- Expanding the use of Epinephrine for moderate to severe respiratory distress.
Prehospital providers should alert the receiving hospital of the ILI patient, hold the patient in the ambulance until their destination is known, instead of immediately moving them into the emergency room. They should clean all equipment that came within 6 feet of the patient and place contaminated reusable patient-care equipment in biohazard bags.
Across the country, New York City is the area of the country with the highest number of cases. The NYC Department of Health and Mental Hygiene recommends that field providers do the following:
- Request additional information from dispatch when sent to respiratory, sick person and fever related calls.
- If limited initial dispatch information is provided, perform initial interview from at least 6.5 feet away to determine if PPE precautions are necessary.
- Ask the patient to place a mask over their mouth and nose before approaching them if they have suspected influenza symptoms. Use a surgical mask or non-rebreather mask (when oxygen is required).
- Avoid droplet-producing procedures whenever possible, including use of nebulizers and bag-valve masks, as well as suctioning or intubation. If bag-valve masks are needed, use BVMs with HEPA filters whenever possible.
- Recommended PPE for taking care of ill/potentially infected patients includes: gloves, N-95 or better respirators, eye protection and gowns. PPE should be donned and doffed according to published guidelines to prevent cross contamination, including faceshield/eye and gown protection when splash or airborne contamination is possible.
- Alert the receiving hospital personnel of the possibility of an infectious patient and hold suspected infectious patients in the ambulance until their destination in the hospital is known.
- At the end of the call, place all PPE in a biohazard bag for appropriate disposal.
- Maintain strict adherence to hand hygiene by washing with soap and water or using hand sanitizer immediately after removing gloves and other equipment and after any contact with respiratory secretions.
- Perform a thorough cleaning of the stretcher and all equipment that has come in contact with or been within 6.5 feet of a potentially infected patient with an approved disinfectant.
- Upon completion of the call, follow CDC interim guidelines for cleaning EMS transport vehicles.
For further information, Harvard Health Publications (HHP), a Division of Harvard Medical School, has published "Swine Flu: How to understand your risk and protect your health," which is a report that explains what the illness is, how it's diagnosed and treated, and how families and businesses can protect themselves against it.Click here for more information, and to purchase and download it as a PDF. In addition to these guidelines, the International Association of EMS Chiefs has created guidelines for assessing existing response protocols and making command decisions on actions. These resources are available below.
- "Swine Flu Top 10: Information points for EMS providers" by Katherine West , BSN, MSEd, CIC
- Official swine flu updates from the CDC
- Official swine flu updates from the WHO
- JEMS Connect discussion on swine flu
- Harvard Health Publications. "Swine Flu: How to understand your risk and protect your health."www.health.harvard.edu/SF
- IAEMSC Recommended Planning for Pandemic Influenza Readiness
- IAEMSC Pandemic Flu Reference Sheet
- IAFC Guidance on Swine Flu