School Infection Prevention Primer: Influenza

School Infection Prevention Primer: Influenza Ruth Carrico PhD RN CIC Assistant Professor School of Public Health and Information Sciences University of Louisville ruth.carrico@louisville.edu

Thanks to Karen Erwin RN MSN, Kentucky State School Nurse Consultant, for her assistance with this presentation and the information provided.Thanks also to Dr. Julio Ramirez, Chief of the Division of Infectious Diseases at the University of Louisville School of Medicine for his preparation of graphics

1. The 2009 pandemic H1N1 strain is similar to the H1N1 strain currently in the seasonal influenza vaccine • True • False

2. Preliminary reports of clinical studies involving the monovalent nH1N1 vaccine indicate: • Comparable response in achieving protective antibody level after a single injection of 15 mcg vs 30 mcg • A higher incidence of local side effects vs seasonal flu vaccine • The need for an adjuvant to boost immunologic response to 15 mcg dose • A satisfactory response among immunosuppressed persons

3. Target groups for H1N1 vaccine include all of the following EXCEPT: • pregnant women • healthy persons aged 18-24 years • infants 0-6 months of age • health care workers aged 50 and over

4. Vaccine-preventable respiratory illnesses other than influenza that may cause significant illness include: • MRSA and pertussis • Pertussis and metapneumovirus • Pertussis, metapneumovirus and respiratory syncytial virus • Pertussis

5. Which of the following best describes environmental cleaning needs for H1N1 prevention : • Routine cleaning practices with focus on high touch surfaces and items • Use of a chemical germicide with an H1N1 label indication • Use of a “green” cleaning agent with an H1N1 label indication • No need to change any cleaning practices or processes

Learning Objectives Identify modes of infection transmission focusing on transmission of respiratory illness 1 Apply transmission knowledge in identifying specific opportunities for transmission of influenza 2 Apply transmission knowledge in recognizing prevention activities relevant to the school setting 3

Modes of Infection Transmission Airborne

Modes of Infection Transmission Airborne Droplet

Modes of Infection Transmission Airborne Droplet Contact

Modes of Infection Transmission Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing

Modes of Infection Transmission Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing Examples include: Tuberculosis Respiratory illnesses with high public health impact*

Modes of Infection Transmission Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing • Larger particles • Drop quickly out of the air • Projected directly into face, eyes, nose and mouth of others Examples include: Tuberculosis Respiratory illnesses with high public health impact*

Modes of Infection Transmission Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing • Larger particles • Drop quickly out of the air • Projected directly into face, eyes, nose and mouth of others Examples include: Tuberculosis Respiratory illnesses with high public health impact* Examples include: Seasonal flu Bacterial meningitis

Modes of Infection Transmission Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing • Larger particles • Drop quickly out of the air • Projected directly into face, eyes, nose and mouth of others • Infectious particles directly contact surfaces, items, and hands • Able to move from surfaces primarily via hands Examples include: Tuberculosis Respiratory illnesses with high public health impact* Examples include: Seasonal flu Bacterial meningitis

Modes of Infection Transmission Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing • Larger particles • Drop quickly out of the air • Projected directly into face, eyes, nose and mouth of others • Infectious particles directly contact surfaces, items, and hands • Able to move from surfaces primarily via hands Examples include: Tuberculosis Respiratory illnesses with high public health impact* Examples include: Seasonal flu Bacterial meningitis Examples include: Seasonal flu MRSA

Modes of Infection Transmission Seasonal Influenza Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing • Larger particles • Drop quickly out of the air • Projected directly into face, eyes, nose and mouth of others • Infectious particles directly contact surfaces, items, and hands • Able to move from surfaces primarily via hands Examples include: Tuberculosis Respiratory illnesses with high public health impact* Examples include: Seasonal flu Bacterial meningitis Examples include: Seasonal flu MRSA

Modes of Infection Transmission Pandemic Influenza Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing • Larger particles • Drop quickly out of the air • Projected directly into face, eyes, nose and mouth of others • Infectious particles directly contact surfaces, items, and hands • Able to move from surfaces primarily via hands Examples include: Tuberculosis Respiratory illnesses with high public health impact* Examples include: Seasonal flu Bacterial meningitis Examples include: Seasonal flu MRSA

Modes of Infection Transmission H1N1 Influenza Airborne Droplet Contact • Small particles • Able to stay afloat in air currents • Directly inhaled • Projected when coughing, talking, sneezing • Larger particles • Drop quickly out of the air • Projected directly into face, eyes, nose and mouth of others • Infectious particles directly contact surfaces, items, and hands • Able to move from surfaces primarily via hands Examples include: Tuberculosis Respiratory illnesses with high public health impact* Examples include: Seasonal flu Bacterial meningitis Examples include: Seasonal flu MRSA

H1N1 Influenza Natural History Incubation Symptomatic Infectious Day 1 Day 3 Day 5 Day 7 Day 9 Infectious up to one day before and seven days after symptoms develop

H1N1 Influenza Natural History Incubation Rapid onset of cough, sore throat, fever, headache, rhinitis, muscle pain, and severe fatigue Symptomatic Infectious Day 1 Day 3 Day 5 Day 7 Day 9 Infectious up to one day before and seven days after symptoms develop

Who Infects Who? Likely sites of transmission: Demographics: School Children/Teenagers 29% Household Adults 59% Workplace Seniors 12% Glass RJ et al. Local mitigation strategies for pandemic influenza NISAC, SAND No. 2005-7955J

School Illness Surveillance • No consistent process that allows statewide or nationwide monitoring of reasons for student absence • Approach by schools is based upon truancy assessment • Paradigm differs from public health

Influenza Illness By Age Groups

Hospitalizations By Age Groups

H1N1 Influenza Incubation period (range 1-4 days) Infectious 1 day prior to onset of symptoms Some infected individuals may be relatively asymptomatic but still able to transmit Survives on non-porous surfaces for up to 24 hours and on hands for up to 30 minutes Disproportionate impact on individuals less than 24 years of age

H1N1 Prevention Immunization Early identification of infected individuals Exclusion of ill persons (work or school) Hand hygiene Environmental cleanliness Respiratory hygiene/cough etiquette

H1N1 Prevention Immunization H1N1 vaccine may soon be available Immunization programs will likely be school-based with children and pregnant women as priority groups May involve 1 or 2 doses (children <10 yrs) May be injectable and/or intranasal Seasonal influenza immunization is also important and should also be a focus

H1N1 Prevention Early Identification Monitoring of reasons for absence Monitoring student as well as school personnel Communication with public health Partner with parents and school personnel to increase compliance with exclusion due to illness Seasonal influenza immunization is also important and should also be a focus

H1N1 Prevention Exclusion Due to Illness Efforts must be made to prevent ill students and school personnel from coming to school/work Ill workers must be sent home immediately Ill students must be separated from others to minimize transmission opportunities Communicating this strategy is best served by early discussion with parents and others Knowledge of social distancing principles

H1N1 Prevention Hand Hygiene Soap and water hand wash when hands visibly soiled Ensure that restroom facilities are working and stocked Alcohol-based hand rubs are very effective The expectation of hand hygiene must be woven into all classes, lunch, recess/breaks, extracurricular activities

H1N1 Prevention Environmental Cleanliness Recall that influenza virus remains alive on surfaces for hours. Pay attention to high touch surfaces including sick rooms. Routine cleaning. Routine cleaning agents or EPA-approved germicides are effective-follow label instructions Maintaining a clean environment requires assistance from students and school personnel

H1N1 Prevention Respiratory Hygiene/ Cough Etiquette Containing respiratory particles Coughing into elbow Coughing or sneezing into tissue Disposal of tissue into garbage receptacle Hand hygiene after coughing, sneezing as well as routinely throughout the day Enable these practices throughout the building

H1N1 Prevention: Heightened Activities If severity and impact is increased Extended exclusion period High risk students and staff stay home Active fever and symptom screening Home quarantine of well siblings Increased social distancing within the school Dismissal (selective, reactive)

Summary Influenza represents significant challenges in the school setting School nurses are key to success as work is done to ensure that prevention activities are in place and students, parents, and school personnel understand and comply Early identification of ill students and school personnel and implementation of infection prevention activities are crucial

1. The 2009 pandemic H1N1 strain is similar to the H1N1 strain currently in the seasonal influenza vaccine • True • False

2. Preliminary reports of clinical studies involving the monovalent nH1N1 vaccine indicate: • Comparable response in achieving protective antibody level after a single injection of 15 mcg vs 30 mcg • A higher incidence of local side effects vs seasonal flu vaccine • The need for an adjuvant to boost immunologic response to 15 mcg dose • A satisfactory response among immunosuppressed persons

3. Target groups for H1N1 vaccine include all of the following EXCEPT: • pregnant women • healthy persons aged 18-24 years • infants 0-6 months of age • health care workers aged 50 and over

4. Vaccine-preventable respiratory illnesses other than influenza that may cause significant illness include: • MRSA and pertussis • Pertussis and metapneumovirus • Pertussis, metapneumovirus and respiratory syncytial virus • Pertussis

School Infection Prevention Primer: Influenza