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Emergencies: Swine Flu

Level 2

Swine Flu EMT Refresher Course EMSNeeds.com Continuing Education

Overview | Assessment | Treatment | Roles

Objectives

Swine Flue EMT Refresher Course

In this Swine Flu course you will earn 2 CE hours. This course is accredited for all levels since all EMS personnel are technically First Responders.

At the end of this course you will be able to:

  • Define confirmed, probable, and suspected cases of swine influenza (H1N1) virus.
  • Clarify the current scope of the pandemic in the United States.
  • Note the differences between historical outbreaks and the current pandemic.
  • Assess the primary signs and symptoms of the swine flu.
  • Recognize emergency symptoms and variations in children compared to adults.
  • Take precautions needed that may affect the medical health of a First Responder.
  • Focus on interim guidance as the circumstances of the pandemic change.
  • Accept and uphold the responsibilities of a First Responder in accordance with the standards of an EMS professional.

References for content used by permission are on the left side under "EMS Resources." A technical :word: when clicked instantly accesses the EMS glossary online.

There are four sections: Overview, Assessment, Treatment, and Roles. Take the section tests in order by clicking the Take Test button. Your results are saved if you are interrupted. Then do the next section—no lost time or effort with mini-test sections!

EMS Course Levels
Overview

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza virus that regularly causes outbreaks of influenza in pigs. Swine flu viruses cause high levels of illness and low death rates in pigs. UPDATE: CDC estimates that the number of deaths could range from 90,000 to several hundred thousand. (Click here to read July 24, 2009 story.)

What is Swine Influenza?

Swine influenza viruses may circulate among swine throughout the year, but most outbreaks occur during the late fall and winter months similar to outbreaks in humans. The classical swine flu virus (an influenza type A H1N1 virus) was first isolated from a pig in 1930. While H1N1 swine viruses have been known to circulate among pig populations since at least 1930, H3N2 influenza viruses did not begin circulating among US pigs until 1998. The H3N2 viruses initially were introduced into the pig population from humans. The current swine flu H3N2 viruses are closely related to human H3N2 viruses.

In late March and early April 2009, cases of human infection with swine influenza A (H1N1) viruses were first reported in Southern California and near San Antonio, Texas. Other U.S. states have reported cases of swine flu infection in humans and cases have been reported internationally as well. CDC and local and state health agencies are working together to investigate this situation. CDC has determined that this swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it not known how easily the virus spreads between people.

Human cases of swine influenza A (H1N1) virus infection have been identified in the United States. Human cases of swine influenza A (H1N1) virus infection also have been identified internationally. The current U.S. case count is provided here.

An investigation and response effort surrounding the outbreak of swine flu is ongoing. Listen and watch here. >>

CDC is working very closely with officials in states where human cases of swine influenza A (H1N1) have been identified, as well as with health officials in Mexico, Canada and the World Health Organization. This includes deploying staff domestically and internationally to provide guidance and technical support.

CDC activated its Emergency Operations Center to coordinate the agency's response to this emerging health threat and yesterday the Secretary of the Department Homeland Security, Janet Napolitano, declared a public health emergency in the United States. This will allow funds to be released to support the public health response. CDC's goals during this public health emergency are to reduce transmission and illness severity, and provide information to assist health care providers, public health officials and the public in addressing the challenges posed by this newly identified influenza virus. To this end, CDC has issued a number of interim guidance documents in the past 24 hours. In addition, CDC's Division of the Strategic National Stockpile (SNS) is releasing one-quarter of its antiviral drugs, personal protective equipment, and respiratory protection devices to help states respond to the outbreak. Laboratory testing has found the swine influenza A (H1N1) virus susceptible to the prescription antiviral drugs oseltamivir and zanamivir. This is a rapidly evolving situation and CDC will provide updated guidance and new information as it becomes available.

How many swine flu viruses are there?

Like all influenza viruses, swine flu viruses change constantly. Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses. When influenza viruses from different species infect pigs, the viruses can reassort (i.e. swap genes) and new viruses that are a mix of swine, human and/or avian influenza viruses can emerge. Over the years, different variations of swine flu viruses have emerged. At this time, there are four main influenza type A virus subtypes that have been isolated in pigs: H1N1, H1N2, H3N2, and H3N1. However, most of the recently isolated influenza viruses from pigs have been H1N1 viruses.

What other examples of swine flu outbreaks are there?

Probably the most well known is an outbreak of swine flu among soldiers in Fort Dix, New Jersey in 1976. The virus caused disease with x-ray evidence of pneumonia in at least 4 soldiers and 1 death; all of these patients had previously been healthy. The virus was transmitted to close contacts in a basic training environment, with limited transmission outside the basic training group. The virus is thought to have circulated for a month and disappeared. The source of the virus, the exact time of its introduction into Fort Dix, and factors limiting its spread and duration are unknown. The Fort Dix outbreak may have been caused by introduction of an animal virus into a stressed human population in close contact in crowded facilities during the winter. The swine influenza A virus collected from a Fort Dix soldier was named A/New Jersey/76 (Hsw1N1).

Blood Pressure

How common is swine flu among pigs?

H1N1 and H3N2 swine flu viruses are endemic among pig populations in the United States and something that the industry deals with routinely. Outbreaks among pigs normally occur in colder weather months (late fall and winter) and sometimes with the introduction of new pigs into susceptible herds. Studies have shown that the swine flu H1N1 is common throughout pig populations worldwide, with 25 percent of animals showing antibody evidence of infection. In the U.S. studies have shown that 30 percent of the pig population has antibody evidence of having had H1N1 infection. More specifically, 51 percent of pigs in the north-central U.S. have been shown to have antibody evidence of infection with swine H1N1. Human infections with swine flu H1N1 viruses are rare. There is currently no way to differentiate antibody produced in response to flu vaccination in pigs from antibody made in response to pig infections with swine H1N1 influenza.

 

911

DefinitionsInterim Guidance on Case Definitions to be Used For Investigations of Swine Influenza A (H1N1) Cases*

  • H1N1 - Swine Infuenza virus
  • Confirmed case - a person with an acute febrile respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests: 1) real-time RT-PCR; 2) viral culture.
  • Probable case - a person with an acute febrile respiratory illness who is 1)positive for influenza A, but negative for H1 and H3 by influenza RT-PCR; or 2) positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay (IFA) plus meets criteria for a suspected case.
  • Suspected case - a person with acute febrile respiratory illness with onset 1) within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection; or 2) within 7 days of travel to community either within the United States or internationally where there are one or more confirmed swine influenza A(H1N1) cases; or 3) resides in a community where there are one or more confirmed swine influenza cases.
Emergency Stop

Assessment

Public health officials within the United States and throughout the world are investigating outbreaks of swine influenza (swine flu).

Can humans catch swine flu?

Swine flu viruses do not normally infect humans. However, sporadic human infections with swine flu have occurred. Most commonly, these cases occur in persons with direct exposure to pigs (e.g. children near pigs at a fair or workers in the swine industry). In addition, there have been documented cases of one person spreading swine flu to others. For example, an outbreak of apparent swine flu infection in pigs in Wisconsin in 1988 resulted in multiple human infections, and, although no community outbreak resulted, there was antibody evidence of virus transmission from the patient to health care workers who had close contact with the patient.

Swine flu is a respiratory disease of pigs caused by a type A influenza virus that regularly causes outbreaks of influenza among pigs.  Swine flu viruses do not normally infect humans; however, human infections with swine flu do occur.  Public health officials have determined that this strain of swine flu virus spreads from human to human and can cause illness.

The outbreak is ongoing and additional cases are expected.

What are the symptoms of swine flu in humans?

The symptoms of swine flu in people are expected to be similar to the symptoms of regular human seasonal influenza and include fever, lethargy, lack of appetite and coughing. Some people with swine flu also have reported runny nose, sore throat, nausea, vomiting and diarrhea.

The symptoms of swine flu in people are similar to the symptoms of seasonal flu in humans and may include:

  • Fever (greater than 100°F or 37.8°C)
  • Sore throat
  • Cough
  • Stuffy nose
  • Chills
  • Headache and body aches
  • Fatigue

Some people have reported diarrhea and vomiting associated with swine flu. Severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.

On April 26, 2009, CDC confirmed additional human cases of swine influenza A (H1N1) virus infection in the United States, bringing the total number of U.S. confirmed cases to 21.

  • This includes cases in California, Texas, Kansas, New York City and Ohio.
  • CDC testing has confirmed the first two human cases of swine influenza A in Kansas. Further testing of the viruses is ongoing to confirm they are the same strain of swine influenza as the other U.S. cases. The first case occurred in a 54-year-old man who had recently traveled to Mexico. The second case occurred in his 49-year-old wife who did not travel to Mexico.
  • CDC testing has confirmed the first human case of swine influenza A (H1N1) in Ohio. The first case occurred in a 9-year-old boy who had recently traveled to Mexico.
  • CDC testing has confirmed 9 human cases of swine influenza A (H1N1) in New York City. Testing of additional specimens in underway.
  • The New York Department of Public Health has sent out a health alert to all doctors in New York City. The alert describes testing and antiviral treatment options for human infections with swine influenza A (H1N1) virus.
  • Testing is being done on additional specimens in Texas. In response to these infections, Texas has cancelled classes at this high-school.Texas is also taking additional steps to cancel large public gatherings in the area.
  • At this time, all the known cases in the United States have recovered and 1 has been hospitalized.
  • CDC continues to work with health officials in Mexico,
  • CDC has provided trained personnel to assist in the ongoing investigations in Mexico, Texas and Southern California.

How common is swine flu infection in humans?

In the past, CDC received reports of approximately one human swine influenza virus infection every one to two years in the U.S., but from December 2005 through February 2009, 12 cases of human infection with swine influenza have been reported.

Can people catch swine flu from eating pork?

No. Swine influenza viruses are not transmitted by food. You can not get swine influenza from eating pork or pork products. Eating properly handled and cooked pork and pork products is safe. Cooking pork to an internal temperature of 160°F kills the swine flu virus as it does other bacteria and viruses.

How does swine flu spread?

Influenza viruses can be directly transmitted from pigs to people and from people to pigs. Human infection with flu viruses from pigs are most likely to occur when people are in close proximity to infected pigs, such as in pig barns and livestock exhibits housing pigs at fairs. Human-to-human transmission of swine flu can also occur. This is thought to occur in the same way as seasonal flu occurs in people, which is mainly person-to-person transmission through coughing or sneezing of people infected with the influenza virus. People may become infected by touching something with flu viruses on it and then touching their mouth or nose.

How does swine flu spread among pigs?

Swine flu viruses are thought to be spread mostly through close contact among pigs and possibly from contaminated objects moving between infected and uninfected pigs. Herds with continuous swine flu infections and herds that are vaccinated against swine flu may have sporadic disease, or may show only mild or no symptoms of infection.

What are signs of swine flu in pigs?

Signs of swine flu in pigs can include sudden onset of fever, depression, coughing (barking), discharge from the nose or eyes, sneezing, breathing difficulties, eye redness or inflammation, and going off feed.

What do we know about human-to-human spread of swine flu?

In September 1988, a previously healthy 32-year-old pregnant woman was hospitalized for pneumonia and died 8 days later. A swine H1N1 flu virus was detected. Four days before getting sick, the patient visited a county fair swine exhibition where there was widespread influenza-like illness among the swine.

In follow-up studies, 76% of swine exhibitors tested had antibody evidence of swine flu infection but no serious illnesses were detected among this group. Additional studies suggest that one to three health care personnel who had contact with the patient developed mild influenza-like illnesses with antibody evidence of swine flu infection.

How can human infections with swine influenza be diagnosed?

To diagnose swine influenza A infection, a respiratory specimen would generally need to be collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding virus). However, some persons, especially children, may shed virus for 10 days or longer. Identification as a swine flu influenza A virus requires sending the specimen to CDC for laboratory testing.

Health Implications of Swine Flu in People

There currently is not enough information to fully assess the health implications of this new swine flu virus in people.

  • Human-to-human spread of swine flu viruses has been documented in the past; however, it has not previously been documented beyond third generation transmission.
  • It seems likely that we are seeing transmission that is ongoing beyond three contacts, but that has not been determined for certain at this time.
  • There is not enough information to indicate the extent of spread of this virus in humans and the illness spectrum associated with human illness with this virus. However, U.S., state and local health officials have enhanced surveillance to identify new cases should they occur.
  • The United States government is working with the World Health Organization and our other international partners to assure early detection and warning and to respond as rapidly as possible to this threat in order to lessen its potential health and socioeconomic impact.

Emergency Warning Signs

In children emergency warning signs that need urgent medical attention include:

  • Fast breathing or trouble breathing;
  • Bluish skin color;
  • Not drinking enough fluids;
  • Not waking up or not interacting;
  • Being so irritable that the child does not want to be held;
  • Flu-like symptoms improve but then return with fever and worse cough;
  • Fever with a rash.

In adults, emergency warning signs that need urgent medical attention include:

  • Difficulty breathing or shortness of breath;
  • Pain or pressure in the chest or abdomen;
  • Sudden dizziness;
  • Confusion;
  • Severe or persistent vomiting.
patient assessment

Treatment

People entering the United States who are experiencing symptoms consistent with swine flu and have traveled to an affected area, or have been exposed to someone possibly infected with swine flu, during the last 7 days should report their illnesses to their health care provider immediately and inform them of their recent travel.

Prevention

People traveling from the United States to affected areas should be aware of the risk of illness with swine flu and take precautions.

To prevent the spread of swine flu on a call:

  • Let others know to avoid contact with ill persons.
  • When you cough or sneeze, cover your nose and mouth with a tissue or your sleeve (if you do not have a tissue).  Throw used tissues in a trash can.
  • After you cough or sneeze, wash your hands with soap and water, or use an alcohol-based hand gel.
  • If you think you are ill with flu, avoid close contact with others as much as possible. Stay at home.  Seek medical care if you are severely ill (such as having trouble breathing).  There are antiviral medications for prevention and treatment of swine flu that a doctor can prescribe.  Do not go to work, school, or travel while ill.

For more information:

Antiviral Drugs and Swine Influenza

Antiviral Drugs

Antiviral drugs are prescription medicines (pills, liquid or an inhaler) with activity against influenza viruses, including swine influenza viruses. Antiviral drugs can be used to treat swine flu or to prevent infection with swine flu viruses. These medications must be prescribed by a health care professional. Influenza antiviral drugs only work against influenza viruses--they will not help treat or prevent symptoms caused by infection from other viruses that can cause symptoms similar to the flu.

There are four influenza antiviral drugs approved for use in the United States (oseltamivir, zanamivir, amantadine and rimantadine). The swine influenza A (H1N1) viruses that have been detected in humans in the United States and Mexico are resistant to amantadine and rimantadine so these drugs will not work against these swine influenza viruses. Laboratory testing on these swine influenza A (H1N1) viruses so far indicate that they are susceptible (sensitive) to oseltamivir and zanamivir.

Benefits of Antiviral Drugs

Treatment: If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious influenza complications. For treatment, antiviral drugs work best if started as soon after getting sick as possible, and might not work if started more than 48 hours after illness starts.

Prevention: Influenza antiviral drugs also can be used to prevent influenza when they are given to a person who is not ill, but who has been or may be near a person with swine influenza. When used to prevent the flu, antiviral drugs are about 70% to 90% effective. When used for prevention, the number of days that they should be used will vary depending on a person’s particular situation.

CDC Recommendation

CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with swine influenza viruses.

  • Oseltamivir (brand name Tamiflu ®) is approved to both treat and prevent influenza A and B virus infection in people one year of age and older.
  • Zanamivir (brand name Relenza ®) is approved to treat influenza A and B virus infection in people 7 years and older and to prevent influenza A and B virus infection in people 5 years and older.

Recommendations for using antiviral drugs for treatment or prevention of swine influenza will change as we learn more about this new virus.

Clinicians should consider treating any person with confirmed or suspected swine influenza with an antiviral drug. Visit: http://www.cdc.gov/swineflu/recommendations.htm for specific recommendations.

beacon


Roles and Responsibilities

Information on the effectiveness of facemasks1 and respirators2 for the control of influenza in community settings is extremely limited. Thus, it is difficult to assess their potential effectiveness in controlling swine influenza A (H1N1) virus transmission in these settings. In the absence of clear scientific data, the interim recommendations below have been developed on the basis of public health judgment and the historical use of facemasks and respirators in other settings.

Interim Recommendations for Facemask and Respirator Use in Certain Community Settings Where Swine Influenza A (H1N1) Virus Transmission Has Been Detected

In areas with confirmed human cases of swine influenza A (H1N1) virus infection, the risk for infection can be reduced through a combination of actions. No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings.

When it is absolutely necessary to enter a crowded setting or to have close contact3 with persons who might be ill, the time spent in that setting should be as short as possible. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. A respirator that fits snugly on your face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through a respirator for long periods of time.

When crowded settings or close contact with others cannot be avoided, the use of facemasks1 or respirators2 in areas where transmission of swine influenza A (H1N1) virus has been confirmed should be considered as follows:

  1. Whenever possible, rather than relying on the use of facemasks or respirators, close contact with people who might be ill and being in crowded settings should be avoided.
  2. Facemasks1 should be considered for use by individuals who enter crowded settings, both to protect their nose and mouth from other people's coughs and to reduce the wearers' likelihood of coughing on others; the time spent in crowded settings should be as short as possible.
  3. Respirators2 should be considered for use by individuals for whom close contact with an infectious person is unavoidable. This can include selected individuals who must care for a sick person (e.g., family member with a respiratory infection) at home.

These interim recommendations will be revised as new information about the use of facemasks and respirators in the current setting becomes available.

1 Unless otherwise specified, the term "facemasks" refers to disposable masks cleared by the U.S. Food and Drug Administration (FDA) for use as medical devices. This includes facemasks labeled as surgical, dental, medical procedure, isolation, or laser masks. Such facemasks have several designs. One type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the nose bridge, and may be flat/pleated or duck-billed in shape. Another type of facemask is pre-molded, adheres to the head with a single elastic band, and has a flexible adjustment for the nose bridge. A third type is flat/pleated and affixes to the head with ear loops. Facemasks cleared by the FDA for use as medical devices have been determined to have specific levels of protection from penetration of blood and body fluids.

2 Unless otherwise specified, "respirator" refers to an N95 or higher filtering facepiece respirator certified by the U.S. National Institute for Occupational Safety and Health (NIOSH).

3 Three feet has often been used by infection control professionals to define close contact and is based on studies of respiratory infections; however, for practical purposes, this distance may range up to 6 feet. The World Health Organization uses "approximately 1 meter"; the U.S. Occupational Safety and Health Administration uses "within 6 feet." For consistency with these estimates, this document defines close contact as a distance of up to 6 feet.

Personal Care

The single best way to prevent seasonal flu is to get vaccinated each year, but good health habits like covering your cough and washing your hands often can help stop the spread of germs and prevent respiratory illnesses like the flu. There also are flu antiviral drugs that can be used to treat and prevent the flu.

What is the best technique for washing my hands to avoid getting the flu?

Washing your hands often will help protect you from germs. Wash with soap and water. or clean with alcohol-based hand cleaner. we recommend that when you wash your hands--with soap and warm water--that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.

Is the H1N1 swine flu virus the same as human H1N1 viruses?

No. The H1N1 swine flu viruses are antigenically very different from human H1N1 viruses and, therefore, vaccines for human seasonal flu would not provide protection from H1N1 swine flu viruses. Vaccines are available to be given to pigs to prevent swine influenza. There is no vaccine to protect humans from swine flu. The seasonal influenza vaccine will likely help provide partial protection against swine H3N2, but not swine H1N1 viruses.

  1. Avoid close contact.
    Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
  2. Stay home when you are sick.
    If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.
  3. Cover your mouth and nose.
    Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
  4. Clean your hands.
    Washing your hands often will help protect you from germs.
  5. Avoid touching your eyes, nose or mouth.
    Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
  6. Practice other good health habits.
    Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

The U.S. Department of Transportation''s EMS Pandemic Influenza Guidelines for Statewide Adoption and Preparing for Pandemic Influenza: Recommendations for Protocol Development and 9-1-1 Personnel and Public Safety Answering Points (PSAPs) are available online at http://www.ems.gov (Click on Pandemic News). State and local EMS agencies should review these documents for additional useful information.












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