Pandemic influenza: How it would progress and what it would require of you
- What hands frequently and thoroughly
- Avoid locations where infection is likely to occur
- Avoid close contact with those who have flu-like symptoms
- Cover coughs and sneezes with tissues, properly dispose of used tissue, and wash hands after handling waste
- Use infection control measures in the home if a household member is ill (TABLE 3)
- Possibly use masks. (No consensus exists on the use of masks by those infected or potentially exposed. Surgical masks may be useful for providers of patient care.)
Physicians can take measures to minimize the chance of spreading the virus in their clinics and to protect themselves and other staff (covered in a previous Practice Alert).3 Infection control guidelines can be implemented in hospitals and other health care facilities, as well as in schools and other high-risk settings.
TABLE 3
Infection control measures for patients cared for at home
| MANAGING THE PATIENT |
| Place the patient in a separate room or separate physically from other household members as much as possible |
| The patient should stay at home while most infectious (5 days after symptom onset) to avoid infecting others. If they have to leave the home they should strictly follow respiratory hygiene |
| Consider having the patient wear a surgical mask |
| ADVICE FOR OTHERS IN THE HOME |
| Non-household members should not enter the home |
| If non-household members need to enter the home they should avoid close contact with the patient |
| Limit the number of household members having contact with the patient Follow hand hygiene after contact with the patient or the patient environment and waste products. This includes hand washing with soap and water or use of an alcohol-based hand rub |
| Consider having direct caregivers wear a surgical mask |
| Wash dishes, utensils, and laundry in warm water and soap |
| Consider antiviral prophylaxis for household members, if it is available |
| Have household members seek care as soon as they develop symptoms of influenza |
Clinical guidelines: Pandemic alert
The recommended clinical approach to a patient suspected of having a novel flu strain will vary depending on the phase of the pandemic.
Through phase 5, in the pandemic alert period, acute febrile respiratory illness will be caused by a novel influenza virus only rarely. Suspect novel influenza only if the patient meets both clinical and epidemiologic criteria. The clinical criteria are fever plus 1 or more of the following: sore throat, cough, dyspnea.
Epidemiologic criteria include travel within the past 10 days to an area affected by highly pathogenic avian influenza out-breaks in poultry or where human cases of novel influenza have been confirmed; and either direct contact with poultry (touching birds or bird feces or surfaces contaminated by bird feces or eating uncooked poultry products) or close contact with a person with confirmed or suspected novel influenza. Occupational exposure through laboratory work with the novel influenza strain would also be considered an epidemiologic criterion, but this occurrence would be rare. Geographic areas affected by avian influenza can be found on the CDC web site (www.cdc.gov/flu/) and World Health Organization web site (www.who.int.en/).
6 Steps to proper management. Once a patient is suspected of having a novel influenza strain, take the following steps.
- Control spread of infection. Consider admitting the patient to a single-patient hospital room. If this is not possible, take precautions to control infection in the home (TABLE 3). Details of hospital infection control precautions can be found on the CDC influenza web site.
- Notify local or state public health departments. Report the suspicious case and ask for advice regarding collecting laboratory specimens and treatment options.
- Obtain clinical specimens requested by the public health department and arrange to have them transported to a designated public health laboratory. These will probably consist of a nasopharyngeal swab, nasal swab, throat swab, and an acute serum specimen (for comparison to a convalescent specimen 2 to 3 weeks later).
- Evaluate alternative diagnoses. Remember that a novel influenza infection can co-infect with a more common organism. Discontinue isolation and antiviral therapy prematurely only if an alternative diagnosis is confirmed with a high-predictive value test, the clinical course is explained by the alternative diagnosis, and the epidemiologic link to the novel influenza strain is not strong.
- Start antiviral treatment.
- Assist the public health department in locating potentially exposed contacts and providing antiviral prophylaxis if recommended.
Clinical guidelines: Pandemic period
During the pandemic period, managing suspected infection differs from the pandemic alert period in several respects.
- Suspected cases need only meet the clinical criteria: fever with sore throat, cough, or dyspnea. These criteria may be modified as the pandemic evolves.
- Hospitalize only those patients with severe complications who cannot be cared for at home.
- Submit clinical specimens to the designated lab only as requested by the public health department. Such monitoring will probably be needed only for a subset of patients to watch the epidemiology of the epidemic or to investigate unusual presentations or failures of preventive therapy.
- Report atypical cases, prophylaxis failures, and other abnormal cases to the public health department.
