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AIRBORNE EPIDEMICS AND RESPIRATORY THERAPY DEPARTMENTS Alphonso Quinones, DHA, MA, RT, RRT-NPS, RPFT, RPSGT, CCT, AE-C, FACHE President, Quinones Healthcare Seminars, LLC Director Respiratory Therapy, North Shore University Hospital

Past Chairman, New York State Licensure Board for Respiratory Therapy and Polysomnography

Objectives

-  To discuss the history of airborne epidemics -  To review the impact of airborne epidemics on

healthcare workers -  To review current respiratory therapy procedures and

infection control measures

Every year, the seasonal flu viruses make people sick. Deaths occur annually and are largely limited to the very young or the very old. In 1918, the flu mutated into something much more virulent. In 1918 flu acted very differently; it seemed to target the young and healthy, being particularly deadly to 20 to 35 year olds. This deadly flu spread quickly around the world, infecting hundreds of millions of people and killing upwards of 5 percent of the world's population.

Overview of the 1918 Spanish Flu Pandemic

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The First Reported Cases of the Spanish Flu

-  No one is quite sure exactly where the Spanish flu first struck. Some researchers have pointed to origins in China -  Fort Riley was a military outpost in Kansas where new recruits were trained before being sent to Europe to fight in World War I. On March 11, 1918, soldiers had come down with flu symptoms and were isolated. -  After five weeks, 1,127 soldiers at Fort Riley had been stricken with the Spanish flu; 46 of them had died. Soon, reports of the same flu were noted in other military camps around the United States. Shortly thereafter, the flu infected soldiers on board transport ships. -  American troops brought this new flu with them to Europe. Beginning in mid-May, the flu started to strike French soldiers as well. The flu traveled across Europe, infecting people in nearly every country.

- When the flu rampaged through Spain, the Spanish government publicly announced the epidemic. Since most people first heard about the flu from its attack on Spain, the new flu was named the Spanish flu. The Spanish flu then spread to Russia, India, China, and Africa. By the end of July 1918, after having infected people all around the world, this first wave of the Spanish flu appeared to be dying out

The Spanish Flu Becomes Incredibly Deadly

- While the first wave of the Spanish flu had been extremely contagious, the second wave of the Spanish flu was both contagious and exceedingly deadly. - In late August 1918, the second wave of the Spanish flu struck three port cities at nearly the same time. These cities (Boston, United States; Brest, France; and Freetown, Sierra Leone) all felt the lethalness of this new mutation immediately.

The First Reported Cases of the Spanish Flu

-  Hospitals quickly became overwhelmed by the sheer numbers of patients. When hospitals filled up, tent hospitals were erected on lawns.

-  Nurses, doctors, and other healthcare

workers were already in short supply because so many of them had gone to Europe to help with the war effort.

-  Desperately needing help, hospitals asked

for volunteers. Knowing they were risking their own lives by helping these contagious victims.

The Spanish Flu Becomes Incredibly Deadly

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Piles of Dead Bodies -  The number of bodies from the victims of the

Spanish flu quickly outnumbered the available resources to deal with them.

-  There weren't enough coffins for all the bodies, nor were there enough people to dig individual graves.

-  In many places, mass graves were dug to free the towns and cities of the masses of rotting corpses.

-  Public campaigns to increase awareness of how to decrease spread of infection

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The  first  avian  influenza  in  humans  was  reported  in    Hong  Kong  in  1997  

•  The  first  avian  influenza  in  humans  was  reported  in  Hong  Kong  in  1997.  It  was  called  avian  influenza  (H5N1).  The  outbreak  was  linked  to  chickens.  

•  Since  then  there  have  been  human  cases  of  avian  influenza  A  (H5N1)  in  Asia,  Africa,  Europe,  Indonesia,  Vietnam,  the  Pacific,  and  the  near  East.  Hundreds  of  people  have  become  sick  with  this  virus.  Up  to  half  of  the  people  who  get  this  virus  die  from  the  illness.  

•  The  chance  of  a  worldwide  outbreak  in  humans  goes  up  the  more  the  avian  flu  virus  spreads  

Severe Acute Respiratory Syndrome (SARS) Epidemic of 2003

-  On February 21, 2003, a 65 year old physician from Guangdong province arrived in Hong

Kong to attend his daughter’s wedding. He inadvertently infected at least 12guest from 6 different countries at the hotel were they stayed (Phua, 2008). The SARS epidemic began…

-  During the severe acute respiratory syndrome (SARS) outbreak of 2003, more than 8,000

infections were reported in 30 countries and killed more than 700.

-  351 cases reported in Canada alone, 72% were infected in a healthcare setting and 45% were in healthcare workers

-  About 25% of all SARS patients required mechanical ventilation

-  Further, as SARS and other experiences have demonstrated, the risk of secondary transmission may be higher in the ICU than in other settings

-  Procedures common in the ICU setting such as endotracheal intubation, open circuit

suctioning, and bronchoscopy, which increase aerosolization of infectious material, have been associated with increased risk of secondary transmission

-  Therapeutic interventions such as noninvasive positive pressure ventilation, administration of nebulized medication, and manual ventilation may also play a role in the spread of infection

Severe Acute Respiratory Syndrome (SARS) Epidemic of 2003

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Severe Acute Respiratory Syndrome (SARS) Epidemic of 2003

-  One of the alarming features of the SARS outbreak was nosocomial spread to healthcare workers

-  In 2003 around the world over 1,700 healthcare workers were stricken with SARS.

-  In Singapore and Toronto, healthcare workers accounted for half of all

SARS cases (Phua, 2008).

H5N1 is a Highly Pathogenic Avian (bird) Flu Virus  

-  H5N1 outbreaks in domestic poultry in parts of Asia and the Middle East. Although H5N1 does not usually infect humans, nearly 600 cases of human cases of H5N1 have been reported from 15 countries since 2003.

- About 60% of people infected with the virus died from their illness.

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-  Early data from the US 2009 H1N1 experience suggested that 50% of healthcare workers with documented H1N1 infections were infected in a healthcare setting

-  The H1N1 flu virus caused a world-wide pandemic in 2009. It is now a human seasonal flu virus that also circulates in pigs.

-  Although the World Health Organization (WHO) announced the

pandemic was over in August 2010, H1N1 is still circulating.

2009 H1N1 Experience

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Important Questions -  What types of precautions are necessary to protect healthcare workers and

their patients?

-  In what situations are increased levels of precautions appropriate?

-  Given the frequency of high-risk respiratory procedures such as intubation and delivery of aerosolized medications can RTs protect themselves during routine care delivery?

-  Data from the SARS experience suggest that there may be an increased risk of secondary infection with the use of NIV and with manual ventilation

-  In some instances in Asia, NIV was used successfully without reports of caregiver infection. Caregivers did use appropriate personal protective equipment.

-  In Canada, healthcare workers who were present for aerosol-producing procedures (aerosol therapy, intubation, NIV) were infected.

-  This difference may be related to the level of personal protective equipment used.

Non-Invasive Ventilation

-  Is NIV is an aerosol-generating procedure? A patient with an intact airway is capable of coughing when the mask is removed, thus expelling contaminated aerosol into the room.

-  In the presence of leaks around the mask, the high flows produced by NIV may also propel aerosol droplets into the environment.

-  Controversy as to efficacy in treating lung injury.

Non-Invasive Ventilation

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-  A spontaneously breathing patient receiving aerosol therapy via a mask or mouthpiece can contaminate the environment and place caregivers at risk.

-  Several studies have demonstrated that the use of a metered-dose inhaler (MDI) is as safe and efficacious as a nebulizer but can be delivered more quickly and with a reduced concern for cross-contamination.

-  In this situation, use of MDI with a mask may be less likely to produce aerosols to contaminate the environment, and efficacy is unaffected.

Delivery of Inhaled Medications: Use of Metered-Dose Inhalers vs. Nebulizers  

-  Mechanically ventilated patients present unique challenges for aerosol delivery of medications. MDI and nebulizers can be adapted for use in ventilator circuits.

-  The nebulizer commonly connects to a T-shaped connector in the ventilator circuit and is driven by compressed gas from the wall source or the ventilator. When the ventilator is used, nebulization is typically in phase with inspiration, reducing medication waste. A MDI requires a spacer or connector with an integral actuator.

Delivery of Inhaled Medications: Use of Metered-Dose

Inhalers vs. Nebulizers  

Ventilator Circuit Filters and Humidifiers  

Other issues to be addressed in Respiratory Care infection control is that of ventilator circuit filtration and humidification.

- Air inlet Filter

-  Inspiratory filter

-  Expiratory Filter

It is unclear which is a more dangerous, unfiltered exhaled gas or possible staff exposure when breaking the circuit to change the filter.

Humidification should be accomplished by heat and moisture exchangers with viral –bacterial filter properties rather than heated humidifiers.

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-  The use of HFOV poses unique infection control challenges in the event of epidemic or pandemic respiratory illness

-  Standard HFOV use involves constant venting of unfiltered, aerosolized gas from the mean airway pressure control diaphragm into the patient room.

-  The entire basic system includes one exhalation valve and two high-pressure dump valves with a design that prevents filtration.

-  Filtered HFOV circuits have been developed since the SARS experience. Although these circuits may be an important contributor to infection control armamentarium, some concern exists regarding whether the addition of filters to these circuits may alter airways resistance. Some data suggest that airways resistance is not significantly impacted by the addition of filters to HFOV circuits (Gentile M, unpublished data).  

HFOV  

Endotracheal Intubation

Anything wrong with this technique?

-  There is a high risk of disease transmission during intubation

-  Consider ICU instead of crash intubation on the floor

-  Sedation and neuromuscular blockade to prevent coughing

-  Procedure should be performed by

the most experienced professional available

-  PPE must be used

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Suctioning Anything wrong with this technique?

-  An aerosol producing procedure

-  There is a high risk of disease transmission during endotracheal suction

-  Closed suction systems must be used

-  PPE must include N95 masks, gloves, gowns, caps, and face shields or goggles

Surge capacity and ventilator rationing

-  How many excess ventilators are routinely available in your hospital?

-  How many are usually available during peak usage months?

-  What would happen in the demand for ventilators far exceeded the supply?

-  What criteria would be used to determine which patients would receive the life sustaining resource?

-  Key principles to consider: - Utilitarianism - Egalitarianism