Egypt ordered a mass slaughtering of pigs as a supposed precaution against swine flu. Vice President Joe Biden told Today show host Matt Lauer that airplane and subway travel posed high risk for flu virus transmission. An ED doc in the Dallas area purportedly circulated a panicked email claiming the National Stockpile is virtually depleted, local EDs are overrun with flu cases and the media is engaging in a full blown cover up of actual flu cases. It seems like swine flu idiots are everywhere. Never has a time been more opportune for Fire/EMS providers to exercise what they do best: keep people from panicking.

Investigation of the 2009 influenza A (H1N1) virus, although genetically linked to pigs, has not been found in swine. Pigs do not appear to be involved in the ongoing spread of infections. In an effort to leave the poor pigs alone, the World Health Organization asked that we replace the term “swine flu” with H1N1 influenza A. Hopefully, Egypt got the memo. Joe “shoot from the lips” Biden certainly got a memo from his boss, President Obama, as the White House went into damage control mode. And the Dallas ED doc has no doubt been deluged by calls from his more sensible colleagues. A Harvard School of Public Health study reveals the extent of the panic: full 46% of Americans believe they or someone in their family will get sick from the H1N1 flu within the next 12 months!

Here’s what you need to do to step up to the plate and put the smack down on swine flu idiocy. The public wants answers. Fire/EMS providers want information. Information overload and panicked messages abound. Firstly, you need three sources of information: the Centers for Disease Control (CDC), the World Health Organization (WHO), and your state and local information filtered through your department or service. The CDC set up a nifty minute-to-minute update site at www.cdc.gov/h1n1flu/whatsnew.htm. Scope it out. Everything you need to know is right there; if you want email updates, RSS feeds, or a Twitter follow, that’s there too. The WHO is not so sophisticated, but offers a wealth of information at www.who.int. Local info should be all this and more, but whoa: no need for overload! Your department (pay attention Chiefs) must keep you up to date on your state and local activities and get it to you before the newspaper or CNN. Local info must be filtered – you don’t care how tissue specimens need to be submitted for pathology evaluation nor do you give a hoot about precautions hospitals are taking when caring for suspected flu patients. Your department must give you manageable, filtered, understandable, and timely information needed to do your job and answer questions from your family and the public.

New York State loves paper, memos and advisories. Their Health Department wasn’t too happy with me when I passed their flu advisories on to my Fire/EMS services with commentary that they contained nothing of value to EMS. Guess what? State EMS folks quickly caught on and have themselves started qualifying transmittals with a listing of the salient points specific to EMS. That’s what I need, what you need, and what we all need in a time when our mailboxes are totally overloaded.

Here are some things the public wants to know. Firstly, “how do I know if I have the flu?” Most influenza infections share common characteristics: high fever, chills, myalgias (body aches), headache, non-productive cough, sore throat, and runny nose. The hallmark differentiating flu from other viral illnesses (such as the common cold) is rapid onset. Common cold virus symptoms begin gradually and tend to worsen over time. Influenza symptoms often begin abruptly, causing a perfectly well person to instantly become extremely ill. Fevers typically exceed 101°F; such body temperatures are quite disabling. Influenza A H1N1 infections have included all these typical flu symptoms and, in a small number of patients, vomiting and diarrhea as well.

Secondly, “what is the flu and how do I get it?” All influenza variants are respiratory viruses. They are transmitted through contact with respiratory secretions from an infected person who is coughing or sneezing. The incubation period ranges from 1 to 5 days between exposure and onset of symptoms; most average 2 days. Viral illnesses are communicable for a maximum of 1 to 2 days before symptoms appear and from 4 to 5 days afterwards. The greatest period of communicability correlates with fever. As a public health tool, 7 days is considered the maximum period during which symptoms would appear following an exposure. For reasons not well understood, children can remain communicable for much longer periods of time.

Thirdly, “how close is too close?” Respiratory secretions are large droplets; they don’t travel very far. The “hot zone” around an infected person is considered to be less than 6 feet. Beyond that, even a forceful cough or sneeze would be highly unlikely to land droplets on another person. Placing a simple surgical mask or oxygen mask over an infected person reduces the “hot zone” to inches. When a patient is masked and health care providers also wear N-95 or better respirator masks, human-to-human spread becomes virtually impossible. There is little evidence that wearing surgical masks in the community will reduce spread of infection but, if it makes the public feel safer, the practice should not be discouraged. At the very least, an asymptomatic infected person (who is potentially communicable) wearing a mask in public significantly reduces their likelihood for infecting others. Airplanes, trains, public transportation, and places of mass assembly are no more dangerous right now that they have been during the past six month flu season. Sure, there is a risk of someone coughing or sneezing on you. The greater risk, however, lie with what or who you touch and whether you remember to wash your hands.

Fourth, “how long can flu virus live on surfaces?” Good question. Respiratory droplets can land virtually anywhere. Doorknobs, telephones, computer keyboards, steering wheels, faucets, dishes…the list is endless. Environmental temperature and humidity strongly affect virus survival; in fact, flu season begins and ends when weather conditions change. As a guideline, influenza viruses will survive on hard non-porous surfaces such as steel and plastic for 24 to 48 hours and cloth, paper, or tissue for 8 to 12 hours. Once picked up on your hands, viruses last for 5 to 15 minutes although within this time period, all it takes is touching your face, mouth, eyes, or nose to transfer the virus into your respiratory tract to produce infection. Two rules are obvious: wash your hands often and keep your hands away from your face.

Fifth, “what should I do if I think I have the flu?” It depends on how sick you are. Despite media accounts, the H1N1 influenza has typically produced only mild illness. If illness is severe, or an infected person has other medical problems, antiviral medications may be helpful to reduce the severity and duration of the illness but only if started within 48 hours of when symptoms began. The best advice is to stay at home so you don’t infect others, call your health care provider, rest, drink plenty of liquids, and use the same cold and fever remedies you ordinarily use. The flu season has not yet ended in the United States; many people worried they had contracted the H1N1 flu have either not had influenza at all or had a seasonal variant of the flu. Many of these illnesses could have been prevented by seasonal flu vaccination. Take the opportunity to remind friends, family, and the public of this. Influenza is a serious illness. Over 200,000 Americans are hospitalized and 36,000 die each year from the flu. WHO estimates there are over 500 million cases worldwide, killing over 250,000 people annually. So who are we testing for the H1N1 flu? People who show signs of febrile respiratory illness and have traveled to or had contact in the past 7 days with people who have either traveled to Mexico, been infected with the H1N1 flu, or live in a community where there have been cases of H1N1 infection. And is the treatment any different for H1N1 flu versus seasonal flu? Nope, not at all.

Sixth, “is there a vaccine?” Not yet. The CDC announced that they had identified the 2009 influenza A (H1N1) virus on May 2nd, 2009 and will begin development of a vaccine. With current technology, this will not be ready for several months, hopefully in time for next year’s flu season. Keep in mind that a variant of H1N1 is included every year in the seasonal flu vaccine and this may possibly provide some immunity to the new virus.

Lastly, “is it safe to eat pork?” Yes; pigs do not carry the H1N1 influenza A, people do. Don’t eat people.

Let’s keep this outbreak in perspective. As all hazard responders to the emergency needs of our communities, we must prepare for the worst. We are not certain what direction the H1N1 flu will take. But the facts are being grossly blown out of proportion. The US city with the largest number of H1N1 cases is New York. Despite 8 million New Yorkers living and working in close quarters, the infection has failed to spread beyond the Queens high school students originally infected in Mexico. New Yorkers ride subways, buses, trains, and crowded elevators every day.
The public looks to firefighters and EMS providers in times of crisis. There are plenty of swine flu idiots out there. Panic serves no one. Let’s help calm the hysteria by offering common sense, practical help to each other and our communities. It’s what we do best.

Mike McEvoy
EMS Editor
Fire Engineering Magazine

Labels: CDC, EMS, H1N1, infection, Mike McEvoy, pandemic, swine flu

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posted by Mike McEvoy
5/03/2009 12:19:00 PM

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The swine flu buzz is causing information overload. There are three things pertinent to the fire service that must be implemented immediately to protect your members, provide excellent patient care, and be a good public health partner. Here's the list:

Fire Service Leaders

1. Immediately notify all members and staff of the emerging problem.
2. Review your plans using the CDC EMS Pandemic Preparedness checklist.
3. Set up an email list and web site to provide continual updates and info for your members.
4. Monitor news reports and government resources. Communicate with your local public health officials. Use the CDC minute-to-minute swine flu update site.

Communications Center/Dispatch Leaders

1. Implement severe respiratory infection (SRI) screening for all callers with chest pain, difficulty breathing, headache, or general illness (sick person). If using the Medical Priority Dispatch System (MPDS), activate the SRI drop down on ProQA or add the following questions to paper card numbers 6, 10, 18, and 26 for further interrogation: (a) has the patient recently been in Mexico (or other outbreak location) or exposed to anyone who has (paying particular attention to those who stayed for 7 days or longer)? (b) are they febrile or have a fever and, if so, is it higher than 101 F (38 C) and (c) do they have a cough or other respiratory illness symptoms?
2. Relay responses to these questions to EMS units before they arrive on scene.

Firefighters and EMS Providers

1. Request additional information from dispatch when sent to respiratory, sick person and fever related calls if limited initial dispatch information is provided.
2. Perform initial interview of all patients from at least 2 meters (6.5 feet) away to determine if personal protective equipment precautions are necessary.
3. Place a mask on all patients with suspected influenza symptoms before approach. Use a surgical mask or non-rebreather mask (when oxygen is required).
4. Avoid droplet producing procedures whenever possible including nebulizers, bag-valve-mask, suctioning or intubation. If bag-valve-masks are needed, use BVMs with HEPA filters whenever possible.
5. Recommended PPE for taking care of ill/potentially infected patients includes: gloves and N95 or better respirators. PPE should be donned and doffed according to published guidelines to prevent cross contamination, including faceshield/eye and gown protection when splash or airborne contamination is possible.
6. Alert receiving hospital personnel of the possibility of an infectious patient as soon as possible and hold suspected infectious patients in the ambulance until their destination in the hospital is known, rather than immediately moving them into the emergency department.
7. Perform a thorough cleaning of the stretcher and all equipment that has come in contact with or been within 2 meters (6.5 feet) with an approved disinfectant, upon completion of the call following CDC interim guidelines for cleaning EMS transport vehicles.

Remember that this is a continually evolving situation. The most severe flu cases so far have been mostly adults from ages 25 to 45, but patients of all ages have been infected, so the same precautions should be used for all patients. We need to stay on heightened alert until this threat has been controlled. As with all infectious diseases, always remember that hand washing is the number one way to decrease transmission!

Mike McEvoy - EMS Editor - Fire Engineering

Labels: CDC, EMS, Mike McEvoy, pandemic, swine flu

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posted by Mike McEvoy
4/27/2009 09:32:00 AM

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Uh oh. By now, you've probably read our breaking news reporting a swine flu outbreak in Southern California and Texas. Is this novel virus with confirmed human-to-human transmission the start of a pandemic? Maybe, maybe not. The CDC released a MMWR report with full details of the US cases investigated as of Friday afternoon, April 24th, 2009. The World Health Organization (WHO) is concerned.

The formula for a pandemic requires 3 things: a novel virus to which all or most people are susceptible, transmissability from person to person, and wide geographic spread. So far, we have a novel virus that appears most people are susceptible to. There has been person-to-person transmission. Wide geographic spread has yet to happen. Essentially, we are (overnight, no less) one step closer to a pandemic than the bird flu. Preliminary CDC incubation period estimates are 1 to 7 days. This is expected to be narrowed to 2 to 5 days with further data. That means we will likely see a pandemic or not within a very short time.

What to do? First, don't panic. Second, wash your hands. Often. Third, take an inventory of where you and your department stand. The CDC Pandemic Influenza EMS Planning Checklist has been available for over 3 years. Review the checklist and make sure you have adequate stockpiles of PPE including N-95 masks and hand hygiene gels. You will not be able to purchase or order them during a pandemic. Check availability of antivirals for your members. Review your sick leave and staffing contingency plans. Assure you have current contacts with public health, government, and hospital officials. Be certain your 911 center can handle calls when no EMS services or hospital beds are available. By now, all these matters should be in place. Make certain they are.

Watch the CDC (www.cdc.gov) and the WHO (www.who.int) for updates and notices. Hopefully, this outbreak remains simply an outbreak.

Mike McEvoy
Fire Engineering EMS Editor

Labels: EMS, Mike McEvoy, outbreak, pandemic, swine flu

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posted by Mike McEvoy
4/24/2009 10:17:00 PM

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