Emerging Infectious Diseases

by Wava Truscott, PhD

The 2009 H1N1 pandemic was not the catastrophic global event many government agencies, healthcare overseers and hospital officials feared. At the time, however, there was every indication it had the potential to be a worldwide disaster. Looking back, was it all just a massively expensive response spurred on by fear mongers and media hype? Or was there a legitimately interpreted threat that pulled the pandemic warning lever, causing us to break open our emergency response protocols, testing our readiness? Are we maximizing the lessons learned?

To fairly answer these questions, we absolutely must:

• Understand why the decision was made to activate the pandemic crisis alarm;
• Assess where response system inadequacies occurred;
• Correct what was weak or missing—both at the facility and staff procedural levels;
• Be alert to new research and global outbreak reports;
• Be prepared if the next wave hits and is more lethal.

In addressing these points, this article will also review the results of a recent survey of 525 Magnet nurses assessing their facility’s state of preparedness. This survey was jointly conducted by Baylor Health Care System and Kimberly-Clark in cooperation with the American Nurses Credentialing Center (ANCC).

What led to the decision to sound the pandemic alarm on the 2009-H1N1 influenza?

On April 12, 2009 public health officials in Mexico reported high numbers of pneumonia/influenza-like illness to the Pan American Health Organization (PAHO), the regional offices of the World Health Organization (WHO). This date marked the first in a series of milestones leading to the declaration of a worldwide H1N1 pandemic on June 11.  A look at the timeline of events over this two-month period helps us understand the informational framework in place as decisions were made.

The severity of the new highly communicable H1N1 influenza A strain became apparent by the beginning of May, when WHO reported a 5.4 percent mortality rate—higher than the 2.5 to 5 percent of the historic 1918 flu pandemic. Statistics reported by the CDC in June indicated that 39 percent of the 2009-H1N1 patients who died in the United States were age 25 to 49 years, similar to the 1918 influenza. Peripartum mothers and their infants were identified to be at higher risk, as were ethnic American Indian and Alaskan natives.

By June 11, 2009, H1N1 influenza cases were confirmed in 74 countries and all continents but Antarctica—just  two months after the initial reports from Mexico. As a result, WHO raised the pandemic alert status to Phase 6—Full Pandemic.

What were additional findings leading to the U.S. decision?

By the time flu season officially started in the United States on October 4, the 2009-H1N1 influenza had already spread to all 50 states. As the highest incidence of seasonal flu historically occurs in February, it was feared there was ample time for the new virus to acquire the genetic capability for increased virulence.  Typical pandemics normally present in three waves—in fact, the most lethal of the 1918-H1N1 influenza wave was the second phase. Since the 2009-H1N1 was just winding down its first phase, the fear was justified. The first pilot lots of H1N1 vaccine became available in July, but full production took several additional months, and vaccines did not become widely available until November 2009.

A scientific and medical report to President Obama in June stated that the 2009-H1N1 virus was the closest match to the 1918-H1N1 influenza A pandemic virus of any naturally emerging influenza strain identified to date. The most significant difference was that the 2009-H1N1 virus was missing the PB1-F2 protein that causes significant lung cell death. However, because it was so contagious, spreading globally in only a few months, there was significant concern that the virus would have plenty of opportunity to pick up the genetics for the lethal protein in any part of the world. The 1918-H1N1 was estimated to have killed up to 100 million people globally, primarily in its second wave. If the 2009-H1N1 had followed a similar pattern, the pandemic could have been catastrophic. Those most vulnerable to severity of disease and death continued to be vibrant young and middle aged adults. This situation had the potential to destabilize our already weakened economy for years to come and to threaten our family and social structure.

The decision to take this very seriously was based on protecting the nation against potentially horrific consequences. If the decision had been to ignore the potential threat and a catastrophic wave had hit, we could never have forgiven our unpreparedness. Pandemic periods last two to three years, and infectious waves emerge unpredictably with uncertain variations in virulence. Vigilance without panic is wisdom, preparing us not only for major disaster scenarios, but also for improving care during less severe, but similar events such as seasonal flu.

Are we better prepared now?

To assess lessons learned from those who saw the 2009-H1N1 pandemic surge of infected patients first-hand, Baylor Health Care System and Kimberly-Clark, in cooperation with the American Nurses Credentialing Center (ANCC), conducted a survey of 525 nurses. The 10-question surveys were distributed both at the Magnet Annual Conference and via e-mail to conference attendees in October 2010. Of the 2,050 surveys disseminated, 25.6 percent were completed. Results of the survey are presented below along with a discussion of the responses.

Question 1: Do you feel that your hospital is more prepared for the upcoming flu season than in years past?

As a result of the 2009-H1N1, hospitals were forced to seriously address preparation and best practices, and more research was focused on virus contamination and transmission. Those who were part of the experience now undoubtedly have more effective procedures in place and better ways to address airborne and droplet transmission.

Question 2: Has the potential for a pandemic influenza outbreak been incorporated into your hospital’s emergency management planning?

From the 2009-H1N1 experience, hospitals found the need to re-examine their pandemic planning and disaster planning. Areas of increased focus for the future include better isolation of potentially infected patients during in-processing, enhanced care of critical patients with respiratory illness, and improved procedures for care of large patient population of patients under airborne, droplet, and/or contact precautions. Additionally, increased attention to proper PPE selection and use are warranted, evaluating performance and likelihood of user compliance along with proper donning and removal techniques.

Question 3: Does your hospital have a pandemic planning executive or committee?

Hospitals should have a pandemic, or a combined pandemic and disaster committee to ensure the most up-to-date strategies are incorporated into the plans, and communicated to management and staff.

Question 4: Has a system been established at your hospital to report unusual cases of influenza-like illness and/or influenza-related deaths to the appropriate health authorities?

One of the take home lessons from 2009-H1N1 was that delayed, inaccurate, and incomplete reporting was a problem hindering accurate situation assessments and appropriate conclusions.

Question 5: How severe do you think this year’s flu season will be?

Results from this question are consistent with current predictions for a mild seasonal flu period in 2011. However, we must not drop our guard, remembering that pandemic waves follow their own time schedule. The 2009-H1N1 wave 1 started in March (immediately after the seasonal flu ended) and was winding down in the fall of 2009, at the official start of the next flu season.

Question 6: Hand washing is critical in helping to prevent the spread of the flu virus. How confident are you that your colleagues follow proper hand washing protocols?

The results from this question indicate room for improvement in hand hygiene. The hands of nurses and other healthcare professionals come in contact with many potentially contaminated surfaces: the patient, the patient’s linens, contaminated PPE, the open box of gloves or masks near the patient, and items contaminated by others who have not washed their hands. Hand hygiene and surface disinfection destroy significant pathogen reservoirs.

Question 7: Do you plan to get a flu vaccine this year?

The flu vaccine is critical to ensure healthy medical staff, reduce absenteeism and prevent the spread of influenza to colleagues, family, friends and contacts. While this result is encouraging, the goal should be 100 percent vaccination rate for healthcare professionals.

Question 8: Public health experts believe that enhanced programs aimed at preventing/reducing healthcare-associated infections (HAIs) are critical to preventing a flu pandemic. Assess your hospital’s HAI prevention program(s).

Only 40 percent of the responders to this question reported their hospital showed “much improvement.” This result could suggest that hospitals have already made great strides and required only minor additional improvements. However, it is more probable that hospitals devoted less attention to HAI prevention improvements generally because they were spending available resources handling staff absenteeism and the surge of influenza patients.

Question 9: Do you believe that the public is sufficiently educated about health benefits of HAI prevention programs?

The responses to this question were clearly divided; however, it is likely that all agree on the importance of public and patient education in HAI prevention. Additional educational efforts especially need to focus on understanding how visitors and patients can impact the spread of infections.

Question 10: Has your hospital developed language- and reading-level appropriate educational materials on pandemic influenza that are easily accessible for all staff?

Physicians and nurses focus a considerable amount of their formal education on infectious diseases and their prevention. However, allied health professionals often do not receive in-depth education training beyond their immediate responsibilities. Education on the “why’s” and “how’s” of infection prevention for aides, orderlies, central service staff, instrument technicians, and other hospital staff is a critical component of infection prevention programs, and requires language- and level-appropriate training.

What new research findings have emerged?

The 2009-H1N1 pandemic generated new research on both the pathology of the influenza virus and on the effectiveness of infection prevention measures. Below are some important findings from recent studies.

Pathogenicity of H1N1

A recent report in <I>Emerging Infectious Diseases<$> described the results of research on genetic reassortment of 2009-H1N1 virus with seasonal H1N1 and H3N2. “The data showed that pandemic (H1N1) 2009 virus has the potential to reassort with seasonal influenza viruses, which may result in increased pathogenicity while maintaining the capacity of transmission through aerosols or respiratory droplets.” This increased virulence occurred without acquiring the PB1/F2 protein (Schrauwen, 2011). The implications of these findings are evident when taken in the context of the situation in Southeast Asia, where cases of the extraordinarily lethal avian influenza A H5N1 still occur.  The 2009-H1N1 spread widely throughout this region as well. The WHO has calculated the current H5N1 human mortality rate to be approximately 60 percent—thus the possibility of a catastrophic combination of highly communicable, highly lethal reassortment is real.

Personal Protective Equipment (PPE)

The Institute of Medicine (IOM) recently published “Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases” emphasizing the need for better education addressing proper selection, use and safe removal of PPE. Research has shown that although respiratory droplets (>5 microns) are thought to be primary route of transmission for influenza, both respiratory and airborne droplet nuclei (<5 microns) are infectious. Thus, N95 respirators are appropriate for exposed, vulnerable care providers, especially while performing aerosol-generating procedures. The CDC has established a hierarchy to describe levels of respiratory protection appropriate for patient vulnerability and exposure risk of procedure (IOM, 2011).

Surface disinfection

The role of environmental contamination has become recognized as an important reservoir for pathogens. Historically, studies have demonstrated influenza virus survival to range from minutes to 48 hours. Recent studies on avian H5N1 influenza A demonstrated survival of up to two weeks on non-porous surfaces in low temperature, low humidity environments (Wood, 2010). Considering the many surfaces contaminated when an influenza patient coughs or is undergoing aerosol generating procedures, it is only logical that surface cleaning and stringent hand hygiene protocols are absolutely critical for transmission prevention. The influenza is easy to destroy using alcohol hand sanitizers or soap and water for hand hygiene, and detergent and water or EPA approved disinfectant wipes or fluids for surface disinfection.

Will there be more waves of infection?

Historically, pandemic outbreaks have occurred cyclically, with each episode lasting over several years. Even the infamous 1918 influenza was unremarkable during its first wave, with a low mortality rate; it was the second wave that was so catastrophic. Facing the history lesson of the 1918 pandemic and the similarities in the 2009-H1N1 virus, the CDC and the President appropriately prepared the nation for a disease that could have caused much more devastation. We must now incorporate the lessons learned from 2009-H1N1 wherever appropriate and educate healthcare staff, stressing the “why’s” along with the “how’s,” in order to improve patient care and staff protection.

I would like to acknowledge Leah Bernstein, PhD, for her writing assistance.

References

• Schrauwen EJA, Herfst S, Chutinimitkul S, et.al. Possible increased pathogenicity of pandemic (H1N1) 2009 influenza virus upon reassortment. <I>Emerg Infect Dis<$> 2011, [Accessed 4-Feb-2011]. http://www.cdc.gov/EID/content/17/2/200.htm.
• Institute of Medicine (IOM). Preventing transmission of pandemic influenza and other viral respiratory diseases: personal protective equipment for healthcare personnel update 2010. National Academy of Sciences. 2011. http://www.iom.edu/Reports/2011/Preventing-Transmission-of-Pandemic-Influenza-and-Other-Viral-Respiratory-Diseases.aspx.
• Wood JP, Young WC, Daniel J, et.al. Environmental persistence of a highly pathogenic avian influenza (H5N1) virus. Environ Sci Technol<$> 2010;44(19):7515-20.

Wava Truscott PhD, MBA, is director of Medical Sciences & Education at Kimberly-Clark Health Care. Ms. Truscott received her doctorate from the University of California, Davis (UCD) in Comparative Pathology with major emphasis areas of Microbiology, Immunology, and Pathology. Her MBA is from the University of La Verne (ULV) and her BS in Botany and Zoology from Brigham Young University (BYU). Dr. Truscott utilizes her years of experience in healthcare, knowledge of disease states and passion for infection prevention, to support product research, create accredited continuing education courses in healthcare, and author healthcare and scientific articles. She is a well known international speaker and has written several book chapters and over 60 professional articles.