Coast Guard Academy H1N1 Influenza Outbreak Overview and Recommendations CDR Joseph Perez USCG HSWL FO New London Senio

1. Coast Guard Academy H1N1 Influenza Outbreak Overview and Recommendations CDR Joseph Perez USCG HSWL FO New London Senior Medical Officer

2. Agenda • Overview of Influenza • Jul 09 CG Academy H1N1 Outbreak Overview • Contingency Plan • Infection Control • Conclusion

3. Background • On June 11, 2009 – the World Health Organization (WHO) declared that a global pandemic of H1N1 influenza was underway and raised the alert level to Phase 6 • Week of July 6, 2009 - CG Academy Clinic noticed a substantial increase in the number ILI symptoms • July 13, 2009 – Clinic received first confirmed positive test result for H1N1 Jul outbreak. • Aug 5, 2009 – Discharged last suspected H1N1 case from isolation from outbreak. • Fall 2009 – Clinic continues to screen patients for H1N1 to stem potential outbreaks

4. Seasonal Influenza • Type A, B • Symptoms: Fever, Fatigue, Body Pain, Headache, Dry Cough, Sore throat • Transmission: One day before to seven days after symptoms, via droplet spread & contaminated surfaces

5. Pandemic Influenza • Global, timing cannot be predicted, occurs when a new influenza A virus emerges and spreads globally. • No immunity existing for people.

6. W-curve of 1918 pandemic

7. Classic pandemic V curve

8. Could 1918 have been worse?

9. Differences between Seasonal influenza and Pandemic influenza • Reference: National Strategy for Pandemic Influenza

10. Epidemiologic Monitoring (CG Health Program Headquarters) CG-112 Notified

11. Symptoms • Generally of sudden onset • Fever, Sore Throat, Cough • Headache, aching muscles, severe weakness, difficulty breathing • Diarrhea, vomiting

12. Influenza-Like Illness • Fever greater than 100.0 and any of the following • Cough, headache, shortness of breath, sore throat, body ache • No other reason accounting for illness

13. How influenza spreads Transmitted through • breathing in droplets containing the virus, produced when infected person talks, coughs or sneezes – distance 6 feet • touching an infected person or surface contaminated with the virus and then touching your own or someone else’s face

14. Incubation period of influenza • Estimates vary • The range described is from 1 to 4 days • Most incubation periods are in the range of 2-3 days

15. Epidemiology/Surveillance Pandemic H1N1 Hospitalizations Reported to CDC

16. Air Force AcademyH1N1 patients Fever (94%), Cough (93%), Fatigue (Sore Throat (86%), headache (84%), Chills (81%), Body Ache (63%), Rhinorrhea (49%), Sinus Congestion (44%), Chest Pain (29%), Stiffness (28%), Dyspnea (25%), Diarrhea (9%), Vomiting (9%), Conjunctivitis (7%), Earache (7%) Source: Am J Prev Med 2010; 38(2) 121-126

17. Epidemiology/Surveillance Pandemic H1N1 Cases Rate per 100,000 Population by Age Group n=3621 n=5774 n=1673 n=382 *Excludes 1,386 cases with missing ages. Rate / 100,000 by Single Year Age Groups: Denominator source: 2008 Census Estimates, U.S. Census Bureau at: http://www.census.gov/popest/national/asrh/files/NC-EST2007-ALLDATA-R-File24.csv

18. Segregation • During the outbreak, the Clinic triaged patients outside of clinic & sent those with ILI symptoms to a separate waiting room

19. Isolation Practices • Aggressively isolated all patients with influenza-like illness • Followed CDC guidance for identifying ILI and isolated patients for 24 hours symptom free or 7 days, whichever was longer Cough Hygiene Isolation Measures

20. Protection • Cadets exhibiting ILI are immediately given face masks to wear while in Clinic • Cadets in isolation are given disinfectant wipes and alcohol-based hand sanitizing gel to utilize when transiting to bathrooms or other common areas. • Clinic staff are provided N95 respirators to utilize during patient treatment • Hand sanitizers are located throughout Clinic and base.

21. N95 filtering facepiece • This (note exhalation valve) • Not this

22. Additional Actions • Clinic tracked location of patients • The Academy increased the frequency of cleaning and increased periodicity of linen service • Clinic leadership discontinued non-essential medical services (non-acute appointments, space-available appointments) Case Tracking Decontamination Measures

23. Total Jul Outbreak Caseload 95 Individuals Tested for H1N1

24. Primary Care Workload During Outbreak Patient Encounters increased 47% from the previous three July averages (1,566) and 121% from the average for any given month (1,024)

25. Clinic Challenges • Medical Officers were admitting patients to the isolation area faster than beds could be found; up to 4 hr wait. • Isolated patients did not consistently follow infection control practices • Internal (within clinic) and external (outside clinic) communication • Clinic staff inconsistently utilized personal protective equipment (PPE).

26. Workload Challenges • Effect of increased workload on staff - tired, inattention to detail, “frazzled” • Increased rounds needed on patients in isolation – Ward census reached 37 patients (7 additional staff members were “borrowed” from other CG Clinics for support) • Public works and janitorial staff were hesitant to conduct work in isolation areas

27. WHO Pandemic Influenza Phases

28. Contingency Plan • Pandemic Influenza (PI) Contingency Planning is a team effort • Leadership is responsible for ensuring PI plans are established & exercised • Staged Response • Stage 1 – General alert. Possible pandemic flu spread to local area. • Stage 2 – Pandemic Flu identified in local population or non-student personnel. • Stage 3 – Confirmed pandemic influenza strain in cadet/student population. • Stage 4 – Wide spread (≥ 10% of AD/Cadets) infection across general Academy population. • Stage 5 – Severe infection causing death and/or degradation of mission capabilities.

29. Stage 1 - General alert. Possible pandemic flu spread to local area • Provide training and information to base personnel • Pandemic Influenza Response Coordinator reviews Pandemic Influenza Contingency Plan for accuracy and completeness • The Commandant of Cadets and LDC Divisions review plan to isolate sick student populations. This plan shall include isolated berthing, hygiene, and sustenance for overflow from Michel Hall. Recommended that (c) division plan for at least 60 isolated beds and (ldc) at least 20.

30. Stage 2- Pandemic Flu identified in local population or non-student personnel • All personnel remain vigilant for signs of influenza like illness. • Clinic identifies isolated location for waiting and treatment area for patient’s exhibiting flu like symptoms. Also ensure proper supplies are on hand in preparation for influx of patients • All personnel are instructed to become familiar with Pandemic Influenza Contingency Plan

31. Stage 3 - Confirmedpandemic influenza strain in cadet/student population • Alert Michel and Munro Hall Building Managers to prepare isolation wards in both buildings to isolate infected student population. • Modify janitorial contract to clean isolations wards • Alert linen service that frequency of service may have to be increased due to increased population on wards.

32. Stage 4 - Wide spread (≥ 10% of AD/Cadets) infection across general Academy population • Implement phone triage to limit unnecessary exposure. • During a severe influenza pandemic temporarily cancel non-essential medical visits.

33. Stage 5 - Severe infection causing death and/or degradation of mission capabilities • Close base to non-essential personnel • Screen at front gate: deny entry for all personnel with ILI or close contact with those with ILI. • Send cadets/students home. If it is impractical for the personnel permanently residing on Academy grounds to leave, then the sick will be separated from the well on different decks in Michel Hall and Munro Hall. • Only essential personnel allowed on Academy – (s) will determine to close the base to all non-essential personnel

34. Need Innovative Measures

35. Logistics • Logistics Planning • PPE – procure separate stock for patients and for healthcare staff • Identify isolation location and beds • Ensure janitorial & laundry services are appropriate for a pandemic response • Ensure staff is trained on PI response • Have a structured communication plan in place

36. Supplies

37. Communication Plan • Alert ALL staff about major operational changes (change in appointment schedules, isolation locations, change in triage process, etc.) • Have one point of contact for all questions from non-clinical staff, the media, other commands, etc. • Have one point of contact (i.e. charge nurse) that coordinates all patient bed assignments • Alert non-clinical staff about status of response and infection control practices on a periodic basis • Provide written (brochure) and verbal infection control recommendations to patients to increase compliance • Post signs on exterior of bldg to alert potentially non-infectious high-risk patients of influenza outbreak

38. Case Tracking

39. Triage • Screen patients outside the building if possible; procure “pop-up” tent in case of inclement weather • Create triage checklist delineating ILI symptoms • Ensure after-hours healthcare personnel are triaging patients in accordance with standard practices • Assign personnel to follow-up (via telephone) with staff or patients that have been sent home sick (improve customer service and clinical care) • During severe outbreak, create telephone triage system to limit patients physical presence in the clinic and screen staff members prior to entering the building

40. Screening

41. Infection Control • Advise patients and clinical staff to follow CDC guidance regarding infection control practices: • Get Vaccinated! • Follow hand hygiene protocols • Social Distancing • Respiratory Hygiene/Cough Etiquette • Standard Precautions • Droplet Precautions

42. Hand Hygiene • Excerpt from COMDTINST M6220.12 Pandemic Influenza Force Health Protection

43. Social Distancing • Maintain a distance of 6 ft or greater from someone suspected of having symptoms of ILI (fever, chills, cough, sneezing, and muscle aches)

44. Cover nose/mouth when coughing or sneezing Cough into the crook of arm/sleeve Use tissues Perform hand hygiene Healthcare facilities shall: Provide tissues and no-touch receptacles for used tissue disposal. Provide dispensers of alcohol-based hand rub; where sinks are available, ensure that supplies for hand washing are available. Respiratory Hygiene/Cough Etiquette

45. Standard Precautions • Standard infection prevention practices that apply to all patients. • hand hygiene; • use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure • safe injection practices

46. Prevents transmission of pathogens spread through close respiratory or mucous membrane contact Separate patients as much as possible, at least > 6 feet Healthcare personnel wear a respirator Patients should wear a mask outside of treatment or isolation room. They should also follow Respiratory Hygiene/Cough Etiquette. Droplet Precautions

47. Protective Equipment • Provide patients surgical masks with one elastic strap rather than individual straps that must be tied • Procure ONE type of respirator for staff and fit test upon reporting to work, ensure healthcare staff wear N95 in treatment rooms AND in waiting areas

48. Other Infection Control Recommendations • Position fans to direct airflow out of patient’s rooms & in through clean rooms • Post signs on isolated rooms of those individuals with ILI • If providing food, provide via individually packaged meals • Consider securing areas that have high likelihood of contamination • Ensure hand sanitizers are filled • Provide separate fridge for contaminated areas

49. Key Points • Aggressive segregation, isolation, and infection control practices are the key to limiting the spread of the virus • Contingency planning is essential to ensure the most coordinated and effective response possible

50. Thank you for this opportunity! Questions? CDR Joseph Perez USCG HSWL FO New London Senior Medical Officer