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CDC, hospital IPs on different pandemic page
Hospitals treat H1N1 like seasonal flu
As it became clear to many public health departments and infection preventionists that H1N1 influenza was acting more like a seasonal influenza virus than a pandemic strain, many broke with the Centers for Disease Control and Prevention and downgraded infection control measures accordingly.
As this issue went to press, the CDC still was recommending that health care workers wear N95 respirators for care of patients under H1N1 isolation precautions. In addition, personnel providing care to or collecting clinical specimens from suspected or confirmed cases should wear disposable nonsterile gloves, gowns, and eye protection such as goggles to prevent conjunctival exposure, the CDC recommends.
However, in a development that may not bode particularly well for future pandemic response, some hospitals in the field broke ranks and began treating what had been a relatively mild infection in the United States much like standard seasonal flu (e.g., use of surgical masks rather than N-95s).
"The question has been whether the SARS-type infection control measures are needed," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville. "There has kind of been a split in the infection control community. I think everyone [initially] adopted the elaborate precautions — as did we. However, as it became apparent that this was not a SARS equivalent, but [similar] to regular influenza, almost immediately there was pressure from infection controllers around the country to have the CDC modify its guidelines."
The CDC is in a difficult position. If lifting the pandemic measures is followed by health care worker infections, they may be lambasted by worker unions and proponents of occupational health measures that favor respirators when dealing with a novel virus. On the other hand, if hospitals and health departments simply drop the measures at the local level, CDC leadership on the issue has effectively been lost.
"I think very quickly they found themselves in the position of leaders who have been overtaken by their troops," Schaffner says.
The CDC declined to be interviewed on the subject, but in response to questions by Hospital Infection Control & Prevention,Arjun Srinivasan, MD, a medical epidemiologist in the CDC division of healthcare quality promotion, stated via e-mail: "We are aware and discussing this issue at this time. As always in such a situation, we are constantly evaluating the situation based on incoming information and making decisions accordingly."
In a statement posted on its H1N1 web site, the CDC noted that "the rationale for the use of [N95] respiratory protection is that a more conservative approach is needed until more is known about the specific transmission characteristics of this new virus."
Everybody wants to do what's right for the safety of health care workers, Schaffner emphasizes, but there is an open question of whether a virus producing typical flu-like illness merits such a full regalia of precautions.
"The more elaborate they are the harder they are to maintain and the more expensive they are," he says. "The supply chain for these very precious consumables is not infinite. We are all having to work very hard to secure our supplies, and with one-time use of N95 respirators, you will run through your supply pretty quickly. Also, we call it 'isolation,' and it does begin to isolate patients from patient care."
The situation was somewhat frustrating in California, where the state and CDC still were advising pandemic-level infection control measures even as some counties and individual hospitals were easing down precautions, says Shannon Oriola, RN, CIC, COHN, lead infection preventionist at Sharp Metropolitan Medical Campus, in San Diego.
"We are still following the N95 recommendations and the state is also following CDC, but you have counties and hospitals in California that have downgraded to droplet [precautions]," she says. "We are trying to stay consistent [with the CDC], but a lot of facilities are recommending N95 for aerosol-generating procedures and using a standard mask for everything else."
Oriola and colleagues implemented pandemic precautions after a suspect patient was admitted April 27 as cases began spreading out of Mexico. "Most of our experience with patients that were H1N1-positive were the ones that came into the emergency department and were discharged home," she says.
As the emergency department was inundated, "source control" of symptomatic patients became a high priority, explained Raymond Chin, MD, hospital epidemiologist at Sharp Metropolitan. A sign was even posted outside the emergency department advising a nonsymptomatic family member accompanying the patient to come in and get a surgical mask for their sick relative.
"'Source control' means basically masking the patient," Chin says. "Health care workers tend to focus on masking themselves. But the problem with the N95 [approach] is that the health care worker will focus on that and then not pay as much attention to hand hygiene and [other basic measures]. They feel that they are protected."
Regardless, as it became clear that the frontlines of the pandemic were going to be the emergency department and clinics, the N95 recommendations became completely impractical, he adds.
"There is no way you can continue using N95s in outpatient settings — it's just impossible," Chin says. "It's impractical, and you have concerns with contaminated masks. Health care workers wear the same mask around from patient to patient."
In general, ambulatory care settings seemed to be less clear about what measures to take, Oriola adds. "Hospitals have received a lot of instruction, but all the other alternative care settings in California have been trying to understand and get direction," she says. "They are getting different messages, and they don't know what to do. We can learn [from this] that we really need to focus more on our outpatient settings because that's where the patients went. Very few patients were hospitalized."
Such reports echoed similar findings by the Center for Biosecurity at the University of Pittsburgh Medical Center, which began contacting hospitals and assessing pandemic planning as soon as the outbreak began.
"There was also some confusion in some places with regards to the use of PPE," says Eric Toner, MD, senior associate at the center. "We heard of some hospitals that had all of their ED staff wearing N95s all that time at least initially, which was certainly unnecessary. We also heard that in some hospitals, clinical units basically had a run on N95s. We know of at least one hospital system that reported that all of the N95s in the central warehouse were gone because the clinical units had grabbed them. They were hoarding them essentially, which is not necessarily unreasonable if you are a unit manager, but problematic for the rest of the system."
While N95s were secure, surgical masks were a concern at Arlington (TX) Memorial Hospital, says Sue Sebazco, RN, an infection preventionist at the facility.
"In-house, we took our masks and pulled them out of our general storage areas on the nursing units," she says. "We were concerned that if we had so many masks out and about people would take them and then we might run short. We didn't know how far we were going with this, so we were very concerned about having [enough] masks. We heard reports of [other hospitals] having masks taken by people — visitors."
Though Sebazco did not have any employee exposures that would warrant the administration of antivirals, there was considerable confusion at some other facilities about the issue, Toner notes. The H1N1 strain is resistant to the antiviral medications amantadine and rimantadine and sensitive to oseltamivir and zanamivir. There was some confusion about using the antivirals for treatment and prophylaxis and the CDC issued guidance clarifying the difference as the pandemic unfolded.
"A problem that was apparent immediately was how best to use antivirals, Tamiflu (oseltamivir) specifically — who to treat, who to prophylax, whether or not to give it to staff," Toner says. "Until it was clarified that Tamiflu and antivirals could be used to both treat and prophylax, some doctors were giving Tamiflu to everybody so they could just keep it at home and have it available. Some were giving it to all staff members who had been exposed to an individual case even if they were wearing proper masks and gowns, which was in excess of current CDC guidelines. The result was spot shortages on Tamiflu in many places."
That led to shortfalls at pharmacies, which typically don't carry many antivirals near the end of flu season, he adds. "Some people who were infected with the virus couldn't get Tamiflu right away because pharmacies were out of it," Toner says. "They had a prescription and went to their pharmacy, but couldn't get it."
Reports of such incidents contributed to the CDC decision to roll out its stockpiles, he says. "Not knowing how bad this would become, I think it was appropriate for them to release a portion of the stockpile to the states.
"Most states, at least as we understand it so far, haven't used those stockpiles," Toner adds.
Certainly, future planning will include an assessment of the diagnostic problems that initially complicated the hospital response, he said.
"Most hospitals don't have access to PCR testing that was necessary to identify this virus, so that was a problem," Toner says. "The rapid flu tests that are typically available were not particularly reliable for this virus. Many hospitals didn't have many rapid tests this time of year anyway, because flu season was pretty much over."
In terms of holding to the pandemic precautions, the CDC is understandably exercising an abundance of caution, he says. "Until there are enough cases in this country to be able to really understand the epidemiology and the case fatality rate, they are being cautious," Toner says. "I think the CDC did a good job, particularly in terms of communication and messaging."
Indeed, as the pandemic unfolded, John M. Barry, author of the definitive book on the 1918 pandemic, was asked by the press what the government should do. "Tell the truth," he replied.
"I think they did," Toner says. "They told the truth as best they knew it. As far as hospitals, they should go back, do an after-action review, and see where they need improvement in their pandemic plan. Those hospitals that don't have pandemic plans better get them."