Exploring the infection prevention and control measures that nurses need to know about to deal with the flu pandemic
Robert J. Pratt, CBE, FRCN, is director, Richard Wells Research Centre, Thames Valley University, London.
Pratt, R.J. (2009) The global swine flu pandemic 2: infection control and preparedness. Nursing Times; 105: 35, early online publication.
This second in a two-part unit on swine flu looks at infection control measures for nurses.
During late spring and early summer, increasing numbers of people became infected with novel swine origin influenza type A virus (influenza A(H1N1)v 2009) and a global pandemic started.
Part 1 of this unit explored the biology of influenza viruses and the origins and characteristics of flu pandemics. This part reviews viral transmission, infection prevention and control and pandemic preparedness.
Keywords: Swine flu, Flu pandemic, Infection control
- This article has been double-blind peer-reviewed
- Be familiar with the elements of national and local pandemic preparedness strategies.
- Understand appropriate flu prevention and control approaches.
As a global flu pandemic caused by A(H1N1)v 2009 influenza virus has been declared by the World Health Organization (2009a), governments all over the world are now implementing their pandemic preparedness strategies.
The UK government has a comprehensive national framework for responding to a flu pandemic (Cabinet Office and Department of Health, 2007), while all NHS organisations and health protection agencies have also developed action plans. These aim to ensure the necessary resources, staff and operational plans are in place and well rehearsed to provide effective healthcare during a turbulent period.
All healthcare staff need to be familiar with their local workplace pandemic preparedness plans and to clearly understand their role in containing and reducing the impact of this potential catastrophe. Everyone needs to be confident they can play their part in ensuring effective care for patients, while at the same time protecting other patients and themselves from infection.
The WHO is responsible for the international surveillance of flu outbreaks and establishing their potential for causing a global pandemic. Criteria are used to categorise the evolution of outbreaks into ‘pandemic alert phases’ (Fig 1).
From February 2009, the WHO incrementally increased these phases until phase 6was declared in June. That meant there was definitive evidence of increased and sustained person-to-person transmission of A(H1N1)v 2009 in different countries throughout the world. The designation of this phase indicates this much-anticipated global flu pandemic is underway and no one yet knows the full impact and consequences it will have (WHO, 2009b).
Measures to limit viral transmission during a flu pandemic are described in detail in the UK flu preparedness plan (Cabinet Office and DH, 2007) and in evidence-based guidance from other national and international health agencies, all of which are available online (Box 1). The core elements of flu preparedness plans designed to contain or mitigate the impact of pandemic flu include:
- Pandemic-specific vaccination (if available);
- Early identification of infected people and treatment with antiviral drugs;
- Personal respiratory hygiene (cough etiquette);
- The use of infection prevention and control measures during episodes of healthcare (especially hand hygiene).
Box 1. Pandemic flu websites for healthcare providers
World Health Organization – Global Alert and Response – Pandemic (H1N1) 2009.
Department of Health (England) – pandemic flu web resource (authoritative information and guidance)
Health Protection Agency (England) - guidance and information
Health Protection Scotland - Pandemic Flu: Guidance for Infection Control in Hospitals and Primary Care Settings
Cabinet Office and Department of Health - Pandemic Flu – A National Framework for Responding to an Influenza Pandemic
NHS (England) - National Pandemic Flu Service
NHS (UK)Department of Health and Health Protection Agency (two guidelines below)
Centers for Disease Control and Prevention (US) – ‘pandemicflu.gov’ (one-stop access to US government H1N1, avian and pandemic flu information)
Health and Human Services (US) – HHS Pandemic Influenza Plan, Supplement 4 Infection Control
Influenza viruses spread easily from person to person via the respiratory route and also from hand-to-face contact if hands are contaminated. Droplet and contact transmission are the most likely routes.
The main method of viral transmission is via large respiratory droplets generated by an infected person during coughing, sneezing or talking. This type of transmission requires close personal contact because, once generated, these droplets are too large to remain suspended in the air and can usually only travel short distances through the air (not more than a metre).
Contact transmission is an important means by which influenza viruses are transmitted, especially via contaminated hands which touch the face and transfer virus to the conjunctiva or to mucous membranes of the nose or mouth.
Direct or indirect contact transmission can easily occur, for instance, when shaking hands with an infected person whose hands are contaminated (as a result of using them to cover their mouth and nose when coughing). Hands can also become contaminated by touching contaminated objects in a patient’s environment, such as stainless steel counters, table tops and plastic washing-up bowls, where the virus can survive for up to 24 hours (Weber and Stilianakis, 2008).
Research has shown that influenza viruses can survive for several days on banknotes. Study investigators suggested that “considering that hundreds of billions of banknotes are probably exchanged every day worldwide, infection from hands contaminated with virus picked up from virus-contaminated banknotes cannot be totally ignored” (Thomas et al, 2008).
Although aerosol-generating procedures, such as endotracheal intubation, suctioning, nebuliser treatment or bronchoscopy, could increase the risk of droplet nuclei (particles 1-10um in diameter) transmission, there is currently no reliable evidence that in other circumstances small particle aerosols are significantly involved in influenza virus transmission (Brankston et al, 2007; Lemieux et al, 2007). However, some opposing scientific opinion cautions against dismissing completely the significance of airborne transmission of influenza viruses (Atkinson and Wein, 2008). Like the pandemic itself, new and evolving research can challenge many of the truisms currently accepted in this fast-moving field.
Influenza virus survival and inactivation
Influenza viruses are susceptible to a wide range of detergents and disinfectant chemicals (especially chlorine solutions). They are therefore easy to kill in the environment compared with many other types of viruses and other microorganisms.
Influenza A virus can survive for at least five minutes when transferred to the hands. As guidance from Health Protection Scotland (Box 1) points out, this is long enough for self-inoculation of the conjunctiva or mucous membranes, and for the virus to be transferred by touch from contaminated hands to other surfaces.
It is reassuring, then, that research has shown that the influenza A virus is destroyed within 30 seconds by alcohol hand disinfectant (Schurmann and Eggers, 1983).
Infection control and personal hygiene
The general public can take basic infection control measures to minimise risk of infection, both to themselves and to others. These include (Cabinet Office and DH, 2007):
- Staying at home when ill;
- Covering the nose and mouth with a tissue when coughing or sneezing;
- Disposing of dirty tissues promptly and carefully – bagging and binning them;
- Washing hands frequently with soap and warm water, or using alcoholic hand disinfectants to reduce spread of the virus from hands to the face, or to other people, particularly after blowing the nose or disposing of tissues;
- Cleaning frequently touched hard surfaces, such as kitchen worktops, light switches, door handles, regularly using normal cleaning products;
- Avoiding crowded gatherings where possible, especially in enclosed spaces;
- If suffering with flu symptoms, wearing a disposable face mask to protect others should it become absolutely essential to go out, for example, to go to hospital;
- Making sure that children follow this advice.
The guidance states that ‘adopting such measures can help mitigate the overall health and wider impact of a pandemic by lowering the clinical attack rate and slowing its development, thereby spreading peak demand on services and enabling them to respond more effectively’ (Cabinet Office and DH, 2007). It also provides guidance to the public on using face masks and respirators, restrictions on travel within the UK, restrictions on public gatherings, school closures and pre-pandemic vaccination.
Key points from guidance are:
- The general wearing of face masks in public places by those who do not have flu symptoms is not recommended (and face masks will not be supplied by government);
- Travel restrictions within the UK would have little positive impact on the total number affected by flu over the entire course of a pandemic and would exacerbate the economic impact, increasing social disruption and adding to business/service continuity. Consequently, the government is unlikely to impose restrictions on internal travel unless it becomes necessary for public health reasons as the pandemic develops;
- The government is unlikely to issue a blanket ban on public gatherings, however it may do if circumstances indicate it would be prudent to do so to protect the public;
- The government would take decisions on whether or not to advise school closures on the basis of an assessment of the emerging characteristics and impact as the pandemic develops;
- Although a population-wide vaccination campaign is unlikely to be possible before or during the first pandemic wave, vaccination may contribute to reducing the impact of subsequent waves if they occur. A pandemic strain-specific vaccine is scheduled to become available in the UK by mid-October at the earliest and the government intends to offer vaccination to high risk groups initially and eventually the entire population.
Further information for the public, including an online/telephone diagnostic facility and authorisation for accessing antiviral medication is available from the National Pandemic Flu Service (Box 1).
Hospital infection control
As large numbers of seriously ill people with flu will require hospital admission, consistently applying clinically effective infection prevention and control measures is essential in protecting all patients from nosocomial transmission of influenza viruses. Effective infection prevention and control measures are comprehensively described in the two pandemic influenza guidance for infection control in hospitals and primary care settings documents and in Pandemic Influenza: Guidance for Infection Control in Critical Care (Box 1). All healthcare providers working in acute care need to be completely familiar with this guidance and to consistently incorporate these recommendations into routine clinical practice.
The DH and HPA (2007) outline key points for infection prevention and control practice. These include:
- Standard infection control principles (Pratt et al, 2007) and droplet precautions (see below) must be used where patients have or are suspected of having flu;
- Good hand hygiene among staff and patients is vital to protect both groups;
- Good respiratory hygiene is essential;
- The use of personal protective equipment should be proportionate to the risk of contact with respiratory secretions and other body fluids and should depend on the type of work or procedure being done. This guidance also clarifies the appropriate use of different types of face masks and respirators, that is, personal respiratory protection.
Applying droplet precautions
The DH and HPA (2007) comprehensively describe effective means for applying droplet infection control precautions, which include the following salient recommendations regarding isolation and personal respiratory protection. For a more detailed list of all recommended measures in this area, see the full guidance.
Placing patients in the facility:
- Ideally patients with flu should be placed in single rooms or cohorted (grouped with other patients who have flu and no other infections) in a segregated area;
- Where patients are cohorted on the basis of epidemiological and clinical information rather than on laboratory-confirmed diagnosis, beds should be at least one metre apart;
- Since influenza viruses are predominantly transmitted by large respiratory droplets and contact with hands and surfaces contaminated by these droplets, special ventilation is not necessary; the doors of segregated areas can remain open (unless a patient is being isolated in a single room for another reason in addition to flu which requires the doors to be shut).
Personal respiratory protection: fluid-repellent surgical masks should be worn by healthcare workers for any close contact with patients, that is, within one metre. These masks provide a physical barrier and minimise contamination of the nose and mouth by respiratory droplets from patients. Disposable respirators that provide the highest possible protection factor - FFP3 respirators - should be worn to carry out procedures that could general aerosols. If an FFP3 respirator is not immediately available, then the next highest category available should be worn, that is, an FFP2 respirator (DH and HPA, 2007).
Environmental cleaning and disinfection in hospitals: this guidance recommends the following measures for effective environmental cleaning and disinfection:
Freshly prepared neutral detergent and warm water should be used for cleaning the hospital or other healthcare environments;
- As a minimum, areas used for cohorted patients should be cleaned daily;
- Clinical rooms should be cleaned at least daily and also between clinical sessions for patients with flu and those for patients not infected with flu, if the same room is used;
- Frequently touched surfaces, such as medical equipment and door handles, should be cleaned at least twice daily and when known to be contaminated with secretions, excretions or body fluids;
- Domestic staff should be allocated to specific areas and not moved between flu and non-flu areas;
- Domestic staff must be trained in correct methods of using personal protective equipment (PPE) and precautions to take when cleaning cohorted areas. They should wear gloves and aprons; and when cleaning in the immediate patient environment in cohorted areas, they should also wear a surgical mask;
- Dedicated or single-use equipment should be used when possible. Non-disposable equipment should be decontaminated or laundered after use in line with local policy;
- Any spillage or contamination of the environment with secretions, excretions or body fluids should be treated in line with local spillage policy.
Part 1 of this unit reviewed the biological characteristics of influenza viruses in general, and pandemic influenza type A viruses in particular. This led to exploring 20th century flu pandemics and an update of current pandemic threats.
This part has examined flu pandemic preparedness plans, viral transmission and hospital infection prevention and control measures. It has also noted important documents and guidelines with which nurses need to be familiar (Box 1). This is especially important regarding infection prevention and control in acute care facilities as it is beyond the scope of this two-part unit to provide detailed guidance.
We are now witnessing the evolution of the first infectious disease pandemic of the 21st century. No one yet knows how this story will end but pandemics are transformational events; nothing is ever the same after they have come and gone.
All doctors, nurses, midwives, HCAs and support staff need to quickly become expert in the prevention, control and containment of this critical event.
For the Portfolio Pages corresponding to this unit see the document above.
Portfolio Pages contain activities that correspond to the learning objectives in the unit. They are presented in a convenient format for you to print out or work through on screen and can be filed in your professional portfolio as evidence of your learning and professional development.
Click here for more Guided learning units
Atkinson, M.P., Wein, L.M. (2008) Quantifying the routes of transmission for pandemic influenza. Bulletin of Mathematical Biology; 70: 3, 820-867.
Brankston, G. et al (2007) Transmission of influenza A in human beings. Lancet Infectious Diseases; 7: 4, 257-265.
Cabinet Office, Department of Health (2007) Pandemic Flu: A National Framework For Responding to an Influenza Pandemic. London: Central Office of Information.
Lemieux, C. et al (2007) Questioning aerosol transmission of influenza [letter]. Emerging Infectious Diseases.
Department of Health, Health Protection Agency (2007) Pandemic Influenza: Guidance for Infection Control in Hospitals and Primary CareSettings. London: Central Office of Information.
Pratt, R.J. et al (2007) epic2: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 65S: S1-S64.
Schurmann, W., Eggers, H.J. (1983) Antiviral activity of an alcoholic hand disinfectant: comparison of the in vitro suspension test with in vivo experiments on hands, and on individual fingertips. Antiviral Research; 3: 25-41.
Thomas, Y. et al (2008) Survival of influenza virus on banknotes. Applied Environmental Microbiology; 74: 10, 3002-3007.
Weber, T.P., Stilianakis, N.I. (2008) Inactivation of influenza A viruses in the environment and modes of transmission: a critical review. Journalof Infection; 57: 5, 361-373.
World Health Organization (2009a) World Now at the Start of 2009 Influenza Pandemic. Geneva: WHO.
World Health Organization (2009b) Current WHO Phases of Pandemic Alert. Geneva: WHO.