Emergency Physicians Monthly Swine Flu Resource

From Emergency Physicians Monthly:

What every emergency physician needs to know about swine flu today*

By Amesh Adalja, MD

*This article is adapted from the author’s earlier report in the Clinician’s Biosecurity Network, available at http://www.upmc-cbn.org/report_archive/2009/04_April_2009/04-09_Swine_Flu_2009/cbnreport_SF1_4-24-09_AM.html

On April 21, 2009, the Centers for Disease Control and Prevention (CDC) issued an MMWR Dispatch describing 2 cases of swine influenza A (H1N1) infection that occurred in Southern California in April. While both patients recovered uneventfully, the isolated viruses harbor novel genetic characteristics not seen in swine flu isolates in the U.S. prior to this event. The other striking feature of these cases is that there was no known contact with swine, raising the question of efficient human-to-human transmission of this virus [1] Subsequent investigation has uncovered 40 additional cases in the United States—all of whom have recovered uneventfully—and reports of severe morbidity and mortality in Mexico. Several other countries including Canada, Scotland, and Spain are reporting confirmed cases.

Why the Emergency Physician Should Know about Swine Flu

As with all emerging infectious diseases, emergency physicians are likely to find themselves on the front line contronting swine flu. It is vital that they be informed with the best information when confronting this potentially deadly virus.

CDC: Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting

From the Centers for Disease Control and Prevention:

Infection Control of Ill Persons in a Healthcare Setting

Patients with suspected or confirmed case-status should be placed in a single-patient room with the door kept closed. If available, an airborne infection isolation room (AIIR) with negative pressure air handling with 6 to 12 air changes per hour can be used. Air can be exhausted directly outside or be recirculated after filtration by a high efficiency particulate air (HEPA) filter. For suctioning, bronchoscopy, or intubation, use a procedure room with negative pressure air handling.

The ill person should wear a surgical mask when outside of the patient room, and should be encouraged to wash hands frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be washed with soap and water before use by other persons. Routine cleaning and disinfection strategies used during influenza seasons can be applied to the environmental management of swine influenza. More information can be found at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.

Standard, Droplet and Contact precautions should be used for all patient care activities, and maintained for 7 days after illness onset or until symptoms have resolved. Maintain 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.

Personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable non-sterile gloves, gowns, and eye protection (e.g., goggles) to prevent conjunctival exposure.

Masks and respirators: Until additional, specific information is available regarding the behavior of this swine influenza A (H1N1), the guidance in the October 2006 “Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic” http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.htmlExternal Web Site Policy. should be used. These interim recommendations will be updated as additional information becomes available.

Interim recommendations:

  • Personnel engaged in aerosol generating activities (e.g., collection of clinical specimens, endotracheal intubation, nebulizer treatment, bronchoscopy, and resuscitation involving emergency intubation or cardiac pulmonary resuscitation) for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator.*
  • Pending clarification of transmission patterns for this virus, personnel providing direct patient care for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator when entering the patient room.

*Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Information on respiratory protection programs and fit test procedures can be accessed at http://www.osha.gov/SLTC/etools/respiratory. Staff should be medically cleared, fit-tested, and trained for respirator use, including: proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use.

Additional information on N95 respirators and other types of respirators may be found at: http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html, and at www.fda.gov/cdrh/ppe/masksrespirators.htmlExternal Web Site Policy.

CDC Releases Swine Flu Guidelines for Clinicians

From the Centers for Disease Control and Prevention:


Clinicians should consider the possibility of swine influenza virus infections in patients presenting with febrile respiratory illness.

If swine flu is suspected, clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.