Link:  http://www.cdc.gov/H1N1flu/vaccination/pregnant_qa.htm

2009 H1N1 Influenza Vaccine and Pregnant Women

September 3, 2009, 2:30 PM ET

General Public

Q: Why does CDC recommend that pregnant women receive the 2009 H1N1 influenza vaccine?

A.  It is important for a pregnant woman to receive the 2009 H1N1 influenza vaccine as well as a seasonal influenza vaccine. A pregnant woman who gets any type of flu is at risk for serious complications and hospitalization.  Pregnant women who are otherwise healthy have been severely impacted by the 2009 H1N1 influenza virus (formerly called “novel H1N1 flu” or “swine flu”). In comparison to the general population, a greater proportion of pregnant women infected with the 2009 H1N1 influenza virus have been hospitalized.  In addition, severe illness and death has occurred in pregnant women. Six percent of confirmed fatal 2009 H1N1 flu cases thus far have been in pregnant women while only about 1% of the general population is pregnant. While hand washing, staying away from ill people, and other steps can help to protect pregnant women from influenza, vaccination is the single best way to protect against the flu.

Q: Is there a particular kind of flu vaccine that pregnant women should get?  Are there flu vaccines that pregnant women should not get? 

A.  There are two type of flu vaccine.  Pregnant women should get the “flu shot”— an inactivated vaccine (containing fragments of killed influenza virus) that is given with a needle, usually in the arm. The flu shot is approved for use in pregnant women.

The other type of flu vaccine — nasal-spray flu vaccine (sometimes called LAIV for “live attenuated influenza vaccine)—is not currently approved for use in pregnant women.  This vaccine is made with live, weakened flu viruses that do not cause the flu). LAIV (FluMist®) is approved for use in healthy* people 2-49 years of age who are not pregnant.

Q. Will the seasonal flu vaccine also protect against the 2009 H1N1 flu?

A. The seasonal flu vaccine is not expected to protect against the 2009 H1N1 flu. Similarly, the 2009 H1N1 influenza vaccine will not protect against seasonal influenza.

Q. Can the seasonal influenza vaccine and the 2009 H1N1 influenza vaccine be given at the same time?

A. It is anticipated that seasonal flu and 2009 H1N1 vaccines may be administered on the same day but given at different sites (e.g. one shot in the left arm and the other shot in the right arm). However, we expect the seasonal vaccine to be available earlier than the 2009 H1N1 influenza vaccine. The usual seasonal influenza viruses are still expected to cause illness this fall and winter. Pregnant women and others at increased risk of complications of influenza are encouraged to get their seasonal flu vaccine as soon as it is available.

Q:  Is the 2009 H1N1 influenza vaccine safe for pregnant women?

A:  Influenza vaccines have not been shown to cause harm to a pregnant woman or her baby.  The seasonal flu shot (injection) is proven as safe and already recommended for pregnant women. The 2009 H1N1 influenza vaccine will be made using the same processes and facilities that are used to make seasonal influenza vaccines.

Q:  What safety studies have been done on the 2009 H1N1 influenza vaccine and have any been done in pregnant women?

A:  A number of clinical trials which test 2009 H1N1 influenza vaccine in healthy children and adults are underway.  These studies are being conducted by the National Institutes of Allergies and Infectious Diseases (NIAID). Studies of 2009 H1N1 influenza vaccine in pregnant women are expected to begin in September.

Q:  Does the 2009 H1N1 influenza vaccine have preservative in it?   

A: There is no evidence that thimerosal (used as a preservative in vaccine packaged in multi-dose vials) is harmful to a pregnant woman or a fetus. However, because some women are concerned about exposure to preservatives during pregnancy, manufacturers will produce preservative-free seasonal and 2009 H1N1 influenza vaccines in single dose syringes for pregnant women and small children. CDC recommends that pregnant women may receive influenza vaccine with or without thimerosal.

Q:  How many 2009 H1N1 influenza vaccine shots will be needed?

A:  Some people, including pregnant women, may need two doses.  We will know more about the number of doses once data from the clinical trials are available.

Q. What will be the recommended interval between the first and second dose if two doses are needed? 

A. This will not be known until clinical trial data are available.  We anticipate that 21-28 days will be needed between the first and second doses.

Q:  Should the 2009 H1N1 influenza vaccine be given to someone who has had an influenza- like illness since between April and now?  Do I need a test to know if I need the vaccine or not?

A. There is no test that can show whether a person had 2009 H1N1 influenza in the past. Many different infections, including influenza, can cause influenza-like symptoms such as cough, sore throat and fever. In addition, infection with one strain of influenza virus will not provide protection against other strains. People for whom influenza vaccine is recommended should receive the 2009 H1N1 vaccine, even if they had an influenza-like illness previously. It is not necessary to test a person who previously had an influenza-like illness. People for whom the 2009 H1N1 influenza vaccine is recommended should receive it, even if they have had an influenza-like illness previously, unless they can be certain they had 2009 H1N1 influenza based on a laboratory test that can specifically detect 2009 H1N1 viruses. CDC recommends that persons who were tested for 2009 H1N1 influenza discuss this issue with a healthcare provider to see if the test they had was either an RT-PCR or a viral culture that showed 2009 H1N1 influenza. There is no harm in being vaccinated if you had 2009 H1N1 influenza in the past.

Q:  What are the possible side effects of the 2009 H1N1 influenza vaccine?

A. The side effects from 2009 H1N1 influenza vaccine are expected to be similar to those from seasonal flu vaccines.  The most common side effects following vaccination are expected to be mild, such as soreness, redness, tenderness or swelling where the shot was given. Some people might experience headache, muscle aches, fever, nausea and fainting.  If these problems occur, they usually begin soon after the shot and may last as long as 1-2 days.  Like any medicines, vaccines can cause serious problems like severe allergic reactions.  However life-threatening allergic reactions to vaccines are very rare.  In 1976, an earlier type of swine flu vaccine was associated with cases of a severe paralytic illness called Guillain-Barre Syndrome (GBS) at a rate of approximately 1 case of GBS per 100,000 persons vaccinated.  Some studies done since 1976 have shown a small risk of GBS in persons who received the seasonal influenza vaccine. This risk is estimated to be no more than 1 case of GBS per 1 million persons vaccinated. Since then, flu vaccines have not been clearly linked to GBS. GBS has a number of different causes, and GBS can occur in a person who has never received an influenza vaccine. The potential benefits of influenza vaccination in preventing serious illness, hospitalization, and death substantially outweigh these estimates of risk for vaccine-associated GBS.

Anyone who has a severe (life-threatening) allergy to eggs or to any other substance in the vaccine should not get the vaccine.  People should always inform their immunization provider if they have any severe allergies, if they’ve ever had a severe allergic reaction following flu vaccination, or if they have ever had GBS.

Q. Can the family members of a pregnant woman receive the nasal spray vaccine?

A. Pregnant women should not receive the live nasal spray influenza vaccine but family and household members and other close contacts of pregnant women (including healthcare personnel) who are 2 through 49 years old, healthy* and not pregnant may receive live nasal spray vaccine.

Q. Can a pregnant healthcare worker administer the live nasal influenza vaccine?

A. Yes.  No special precautions are (such as gloves) are necessary. Hands should be washed or cleaned with waterless hand sanitizer before and after administering the vaccine or having any direct contact with patients in a health care setting.

Healthcare Providers

Q.  Where can healthcare providers obtain 2009 H1N1 influenza vaccine?

A.  The CDC will be distributing the 2009 H1N1 influenza vaccine to each state. If healthcare providers want to provide H1N1 vaccine directly to their patients, they can contact their local health department to obtain H1N1 vaccine. Information to direct providers interested in obtaining vaccine to appropriate public health contacts in their state is available.

Q.  How will healthcare providers obtain other supplies necessary for vaccination?

A.  The vaccine will be distributed with a kit which will contain needles, syringes, sharps containers and alcohol swabs.

Q.  How much does the vaccine cost?

A.  The vaccine will be provided free; however, healthcare providers may bill for vaccine administration.

Q.  If a pregnant woman delivers before receiving her second dose of vaccine, should she still receive the second dose?

A.  Yes. In addition to protecting her from infection, infants less than 6 months old will not be able to be vaccinated so it is recommended that everyone who lives with or provides care for infants less than 6 months of age receive both the seasonal influenza vaccine and 2009 H1N1 influenza monovalent vaccine to provide protection for the infant.
One recent study conducted in Bangladesh, assessed the effectiveness of influenza immunization for mothers and their young infants.  Inactivated influenza vaccine reduced proven influenza illness by 63% in infants up to 6 months of age. This study confirmed that maternal influenza immunization is a strategy with substantial benefits for both mothers and infants.

Q.  Where can healthcare providers get more information about the 2009 H1N1 influenza vaccine?

A.  Information is continually updated at http://www.cdc.gov/h1n1flu/vaccination/

”Sure,” the woman says. ”Let me go wash my hands first.”

After she washes her hands, they go upstairs.

Before they have sex, she goes to the bathroom to wash her hands.

After they are finished, she washes her hands again.

This is really starting to annoy the male doctor so he says, ”You know, you must be a surgeon, because you keep washing your hands.”

Angry at this remark, the woman says, ”Well, you must be an anesthesiologist, because I didn’t feel a thing!”

But I digress….. 

The IOM has reaffirmed the need for fit-tested N-95 to be worn by healthcare workers when dealing with a suspected case of H1N1.   If properly fitted and worn correctly, N95 respirators filter out at least 95 percent of particles as small as 0.3 micrometers, which is smaller than influenza viruses.

http://omniphysicians.com/2009/09/04/n-95s-h1n1/

This is a MedScape article reporting on the IOM recommendations.  Which is kinda like USA Today interpreting NY Times or Rush Limbaugh interpreting Antonin Scalia or Al Fraken interpreting Bertrand Russell.

http://omniphysicians.com/2009/09/04/healthcare-workers-n95-and-h1n1/

This is a MMWR report on  a group of preschool teachers with nausea, dizziness, headache, and numbness and tingling of fingertips after consumption of brownies purchased 3 days before from a sidewalk vendor.  Alice B. Toklas, anyone?

http://omniphysicians.com/2009/09/04/inadvertent-ingestion-of-marijuana/

Paul R

Link:  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5834a2.htm?s_cid=mm5834a2_e

MMWR September 4, 2009 / 58(34);947-950

Inadvertent Ingestion of Marijuana — Los Angeles, California, 2009

On April 8, 2009, the Los Angeles Police Department (LAPD) notified officials from the Los Angeles County Department of Public Health (DPH) in California about a group of preschool teachers with nausea, dizziness, headache, and numbness and tingling of fingertips after consumption of brownies purchased 3 days before from a sidewalk vendor. To characterize the neurologic symptoms and determine whether these symptoms were associated with ingestion of the brownies, the police and health departments launched a collaborative investigation. This report summarizes the results of that investigation, which detected cannabinoids in a recovered sample of the brownies. Two patients sought medical attention, and one patient’s urine and serum tested positive for 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THC-COOH), a marijuana metabolite. The findings in this report demonstrate the utility of a collaborative investigation by public health and law enforcement.The findings also underscore the need to consider marijuana as a potential contaminant during foodborne illness investigations and the importance of identifying drug metabolites by testing of clinical specimens soon after symptom onset.

On the morning of April 7, 2009, a preschool teacher put brownies, which she had purchased on April 5, on a table in a break room to share with staff. The day before, she also had given two brownies to her adult son at home. Five preschool teachers (not including the teacher who had purchased the brownies) and the teacher’s adult son were the only persons who ate the brownies. Each person ate only one brownie. At approximately 1:30 p.m., the preschool director and the administrator noticed that one of the teachers suddenly looked drowsy and was complaining of drowsiness, ataxia, dizziness, shortness of breath, and numbness and tingling of the face, forehead, arms, and hands. When the director and administrator learned that the teacher who had shared the brownies had purchased them from a sidewalk vendor for a church fundraiser, they suspected the affected teacher’s drowsiness was associated with her ingestion of the brownie 30 minutes before onset of symptoms. The teacher did not seek medical care.

The brownies were sold as single, unlabeled units, individually wrapped in plastic wrap, costing $1.50 each. The preschool director contacted the head pastor of the church, who reported that the church had not held a fundraiser, and the pastor subsequently notified LAPD to investigate. After interviewing persons at the church and the preschool, LAPD suspected foodborne illness and contacted DPH on April 8.

Public health officials conducted a site visit at the preschool on April 9 and used a standard questionnaire to interview the affected persons about food history, medical history (including any drugs, herbal supplements, or medications taken), symptoms experienced, and time to onset (Table 1). No one reported taking any medications or herbal supplements. DPH and LAPD later discovered that the son of the teacher who had purchased the brownies also was possibly exposed, and DPH interviewed him using the same questionnaire on April 21. All six affected persons reported never having used marijuana or any other illicit drugs. The brownies were the only common food item reported among the affected persons. All six affected persons reported at least nine symptoms, and all had drowsiness, fatigue, and ataxia (Table 2). All the affected preschool teachers were able to continue conducting classes that day. The time to onset of symptoms after ingesting the brownie ranged from 30 minutes to 3 hours, with a mean of 93 minutes.

Investigators considered a broad spectrum of etiologies, and consulted the DPH Technical Advisory Group (TAG) to develop investigative strategies. The TAG is a cadre of subject matter experts who possess security clearances and routinely share and assess investigation information between public health and law enforcement. The TAG includes a medical toxicologist, psychiatrist, laboratorian, veterinarian, specialists in environmental health, infectious disease, and radiation management, and a local FBI official. The clinical history and timing of events did not support a psychogenic etiology; each of the affected persons consumed a brownie at a different time of the day and experienced and reported symptoms independently at various times throughout the day. Moreover, some of the affected persons reported their symptoms to preschool administrators the next day, without knowledge of the previous day’s events. Based on the constellation of reported symptoms, affected persons were asked about specific exposures to similarly acting agents, such as Jimson weed or diphenhydramine. Several affected persons reported that the brownies had a medicine-like aftertaste or smell; however, all six affected persons ate an entire brownie. One teacher (who did not report symptoms and was not included in the analysis) reported biting a brownie but immediately spitting it out, complaining of an unusual taste.

Two of the teachers sought medical attention at urgent-care facilities on the day of exposure: one was a breastfeeding mother, and the other had the most profound illness compared with the rest of the affected persons (illness that included cardiopulmonary symptoms). The latter was diagnosed with foodborne illness and was prescribed antibiotics. The breastfeeding mother nursed her infant at 9:00 a.m., approximately 90 minutes after eating the first half of her brownie. The infant did not show any signs of illness. The mother ate the second half of her brownie at 1:00 p.m. As part of the medical evaluation, she underwent serum and urine toxicology screening at approximately 7:00 p.m. that evening. The blood and urine samples were screened at a clinical laboratory for amphetamines, barbiturates, benzodiazepines, cocaine metabolites, cannabinoids, methadone, methaqualone (urine only), opiates, phencyclidine, and propoxyphene metabolites by immunoassay and confirmed by gas chromatography-mass spectrometry (GC/MS). Serum parent-compound 9-delta-tetrahydrocannabinol (THC) level was <1 ng/mL, and THC-COOH was 27 ng/mL. Urine THC-COOH level was 66 ng/mL. Subsequent urine drug screenings of all six of the exposed persons (collected >8 days postexposure) were negative for cannabinoids and all the other drugs screened in the panel described. On May 20, a recovered sample of brownies was tested at the LAPD Scientific Investigation Division Laboratory for these same substances and additional substances (e.g., anabolic steroids) by GC/MS and was found to be positive for cannabinoids.

All affected persons recovered completely within hours after the exposure. Symptom duration ranged from 3 to 10 hours, with a mean of 6.25 hours. DPH environmental health inspectors and LAPD conducted a search on April 19 but were unable to locate the sidewalk vendor. No charges were brought against the teacher who purchased the brownies. No further complaints from affected persons or reports of additional symptomatic persons have been received to date. The sidewalk vendor has not been located to date.

Reported by: S Fogleman, MSN/MPH, C Rangan, MD, J Kennedy, MPH, M Santos, M Kim, MD, R Reporter, MD, SM Teutsch, MD, JE Fielding, MD, D Diamond, MD, Los Angeles County Dept of Public Health.

Editorial Note:

Marijuana is the most commonly used illicit drug in the United States. Among persons aged ≥12 years, an estimated 5.8% had used the drug during the preceding month, according to the 2007 National Survey of Drug Use and Health (1,2). Inadvertent marijuana ingestion has been reported previously (3–7). Similar episodes of inadvertent ingestion of marijuana occurred in Colorado in 1978 (3) and in California in 1981 (4), where persons unknowingly ingested marijuana in baked goods. The constellation of symptoms described in this report is similar to other instances in which persons reported drowsiness (4,5,7), fatigue (6), ataxia (6,7), and dizziness (3,4,6). Accidental marijuana ingestion has led to coma in children (5). Therefore, pediatricians should be alert for signs of accidental ingestion.

THC is the major psychoactive ingredient of marijuana and is lipophilic. After exposure, THC is rapidly incorporated and distributes to the adipose tissue, liver, lungs, and spleen. It is then released back into the blood slowly and eventually is metabolized and changed into THC-COOH, which is excreted in the urine. THC-COOH is the most important compound for clinical testing purposes, and GC/MS procedures are considered the gold standard for testing (8).

Multiple factors can influence the duration of detectability of THC metabolites in the urine, including frequency of marijuana use, timing of specimen collection, body fat content, and degree of urine dilution. The window of detection for THC-COOH ranges from a few days in infrequent marijuana users to weeks or months in frequent users (8). A previous study revealed an average detection duration of approximately 6 days among subjects who ingested marijuana-laced brownies containing a total dose of 22.4 mg THC (equivalent to the amount in one standard marijuana cigarette) and approximately 6.5 days from the same subjects after ingesting 44.8 mg THC (9). Although the dose of marijuana ingested by the affected persons described in this report is unknown, negative test results for specimens obtained >8 days after exposure would be an expected result if the THC equivalence in the brownies was similar to the recreational dosing that was given in that study (9).

The collaborative investigation was notable for the coordination between public health officials and law enforcement during the outbreak. The benefits of law enforcement involvement included early notification of the event to public health officials, collaborative interviews of the brownie purchaser, and assistance in testing urine specimens and the brownie sample at the LAPD laboratory. The demonstrated cooperative investigation and response capabilities included collection of clinical specimens in the context of foodborne illness with suspected chemical contamination, maintenance of chain-of-custody of laboratory specimens, maintenance of confidentiality of health information, and exclusion of psychogenic illness in the presence of unusual neurologic symptoms.

References

1. Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: national findings. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2008. Available at http://oas.samhsa.gov/nsduh/2k7nsduh/2k7results.pdf.
2. Substance Abuse and Mental Health Services Administration. [Tables of illicit drug use among persons 12 years and older in 2006 and 2007]. National Survey on Drug Use and Health 2006 and 2007. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2007. Available at http://oas.samhsa.gov/nsduh/2k7nsduh/tabs/lotsect1pe.htm.
3. CDC. Foodborne marijuana outbreak—Colorado. MMWR 1978;27:404–5.
4. CDC. Food-borne illness due to inadvertent consumption of marijuana—California. MMWR 1980;30:527–8, 533.
5. MacNab A, Anderson E, Susak L. Ingestion of cannabis: a cause of coma in children. Pediatr Emerg Care 1989;5:238–9.
6. Meier H, Vonesch HJ. Cannabis intoxication after eating of a salad. Schweiz Med Wochenschr 1997;127:214–8.
7. Weinberg D, Lande A, Hilton N, Kerns DL. Intoxication from accidental marijuana ingestion. Pediatrics 1983;71:848–50.
8. Musshoff F, Madea B. Review of biologic matrices (urine, blood, hair) as indicators of recent or ongoing cannabis use. Ther Drug Monit 2006;28:155–63.
9. Cone EJ, Johnson RE, Paul BD, Mell LD, Mitchell J. Marijuana-laced brownies: behavioral effects, physiologic effects, and urinalysis in humans following ingestion. J Anal Toxicol 1988;12:169–75.

Link:  http://www.usfa.dhs.gov/downloads/pdf/publications/fa_323.pdf

Edited Summary:  “Over the past decade, numerous law enforcement officers, firefighters, and emergency medical services (EMS) workers were injured or killed along roadways throughout the United States. In 2008, as with the prior 10 years, more law enforcement officers died in traffic-related incidents than from any other cause; National Law Enforcement Officers Memorial (NLEOM, 2008) over the past 12 years, an average of one officer per month was struck and killed by a vehicle in the United States. (FBI, 2007) Preliminary firefighter fatality statistics for 2008 ref lect 29 of 114 firefighters killed on duty perished in motor vehicle crashes, (USFA, 2009a) similar to figures posted in previous years. According to a 2002 study (Maguire, et al.) that aggregated data from several independent sources, at least 67 EMS providers were killed in ground transportation-related events over the 6 years from 1992 to 1997.

These sobering facts clearly demonstrate the importance of addressing vehicle characteristics and human factors for reducing the morbidity and mortality of public safety personnel operating along the Nation’s highways and byways…..”

Key Findings:  The increased use of retroreflective materials holds great promise for enhancing the conspicuity of emergency vehicles.

Both visibility and recognition are important facets of emergency vehicle conspicuity.

The use of contrasting colors can assist drivers with locating a hazard amid the visual clutter of the roadway.

Fluorescent colors (especially fluorescent yellow-green and orange) offer higher visibility during daylight hours.

There is limited scientific evidence that drivers are “drawn into” highly-visible emergency vehicles.

It is theoretically possible to “over-do” the use of retroreflective materials and interfere with drivers’ ability to recognize other hazards.

Effectiveness of the “Battenburg” pattern in the UK appears primarily related to its association with police vehicles in that country.

Opportunities

Outline vehicle boundaries with “contour markings” using retroreflective material, especially on large vehicles.

Concentrate retroreflective material lower on emergency vehicles to optimize interaction with approaching vehicles’ headlamps.

Consider (and allow) the use of fluorescent retroreflective materials in applications where a high degree of day-/night-time visibility is desired.

Using high-efficiency retroreflective material can improve conspicuity while reducing the amount of vehicle surface area requiring treatment.

For law enforcement vehicles, retroreflective material can be concentrated on the rear to maintain stealth when facing traffic or patrolling.

Applying distinctive logos or emblems made with retroreflective material can improve emergency vehicle visibility and recognition.

Link:  http://www.medscape.com/viewarticle/708354?src=emailthis

Medscape report on N95 and H1N1, 9/3/09

September 3, 2009 — To help protect against respiratory infection, healthcare workers who interact with patients suspected or confirmed of being infected with the novel pandemic influenza A strain H1N1 should wear fitted N95 respirators, which filter better than looser medical masks, according to a letter report released September 3 by the Institute of Medicine (IOM).

“Based on what we currently know about influenza, well-fitted N95 respirators offer healthcare workers the best protection against inhalation of viral particles,” committee chair Kenneth Shine, executive vice chancellor for health affairs at the University of Texas System in Austin, and former IOM president, said in a news release. “But there is a lot we still don’t know about these viruses, and it would be a mistake for anyone to rely on respirators alone as some sort of magic shield. Healthcare organizations and their employees should establish and practice a number of strategies to guard against infection, such as innovative triage processes, handwashing, disinfection, gloves, vaccination, and antiviral drug use.”

Although the IOM letter endorses the current US Centers for Disease Control and Prevention (CDC) recommendation for respiratory protection against H1N1, it emphasizes that the use of N95 respirators should be only 1 element of a comprehensive program of workers’ and healthcare organizations’ infection-control strategies. If the prevalence of clinically apparent H1N1 infection increases during this fall influenza season, it will be vitally important to protect healthcare workers from infection. In light of their central role in treating patients, such measures could reduce the overall impact of this pandemic.

Even with the best available scientific evidence to date, the extent of airborne transmission of H1N1 is unknown. It is also unclear whether physical contact with contaminated fluids or surfaces is needed for infection to occur. The letter therefore recommends increased research to address these unanswered questions and to design and develop better protective equipment to improve the comfort, safety, and job performance of healthcare workers.

However, studies suggest that inhalation of airborne viruses is a probable route of influenza infection, supporting the use of respiratory protection during an outbreak. Because the IOM was specifically charged with evaluating personal protective equipment designed to reduce the risk for respiratory infection, the committee focused on studying the efficacy of medical masks and respirators.

N95 respirators and medical masks are similar in appearance and both cover the nose and mouth. Medical masks fit loosely over the face, whereas respirators are designed to form a tight seal against the wearer’s skin. When properly fitted and worn as recommended, N95 respirators filter out at least 95% of particles 0.3 μm or larger, which is a threshold smaller than the influenza virus particle.

Because of the limited scope and time frame in which develop this report, the IOM committee did not address how to implement their recommendations, did not determine likely costs and needed supplies, and did not evaluate the effects of vaccination, prophylactic use of antiviral drugs, or other infection-control measures. To reduce the probability that healthcare workers will be exposed to and infected by H1N1, the committee stressed the importance of using a variety of infection-control strategies.

Specific recommendations of the IOM committee regarding the use of respirators by healthcare workers are as follows:

• Healthcare workers, including those in nonhospital settings, who are in close contact with patients who have novel H1N1 influenza or influenza-like illnesses should use fit-tested N95 respirators or respirators that are demonstrably more effective. This should not be a stand-alone solution, but a single measure in the continuum of safety and infection-control efforts to decrease the risk for infection.
• The IOM committee endorses the current CDC guidelines and recommends continuing to follow them until or unless additional evidence shows that other forms of protection or other guidelines are equally or more effective.
• Employers should ensure that the use and fit testing of N95 respirators is in accordance with Occupational Safety and Health Administration (OSHA) regulations. Furthermore, healthcare workers should use these respirators in accordance with regulations and employer policies.
• The committee does not recommend the use of N95 respirators for all healthcare workers, only for those in initial contact with patients presenting with undetermined febrile respiratory illnesses and those in close contact with individuals with confirmed or suspected novel H1N1 influenza.
• Evidence is insufficient at this time to completely define close contact for all settings and situations. However, close contact has generally been defined as being within 6 feet of a patient. The entrance of a healthcare worker into an enclosed space with a patient, such as in an isolation room, has been shown to increase the worker’s risk for infection.

Specific recommendations of the IOM committee regarding the need to increase research on influenza transmission and personal respiratory protection are as follows:

• Further research is needed to resolve unanswered questions about the relative contribution of different routes of influenza transmission.
• Randomized clinical trials should test the efficacy of personal respiratory protection technologies in a variety of clinical settings.
• The next generation of personal respiratory-protection technologies for healthcare workers should be designed and developed to enhance safety, comfort, and ability to perform work-related tasks.

“As noted throughout this report, respiratory protection is 1 part of a systematic multipronged infection prevention and control strategy,” the authors conclude. “The goal is to minimize risk and decrease the number of healthcare workers with potential exposure to undetermined febrile respiratory illnesses and to accurately and rapidly diagnose patients who necessitate antivirals, antimicrobials, and other essential medical and public-health interventions.”

The CDC and OSHA requested and supported this study. They note that any opinions, findings, conclusions, or recommendations expressed in the letter are those of the author(s) and do not necessarily reflect the view of the supporting organizations or agencies.

Institute of Medicine. September 3, 2009. Respiratory protection for healthcare workers in the workplace against novel H1N1 influenza A: A letter report. Washington, DC: The National Academies Press.

Date:  Sept. 3, 2009

Contacts:  Christine Stencel, Senior Media Relations Officer

Alison Burnette, Media Relations Assistant

Office of News and Public Information

202-334-2138; e-mail news@nas.edu

http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12748

FOR IMMEDIATE RELEASE

IOM Recommends N95 Respirators to Protect Health Care Workers From H1N1 Flu,

Cautions Against Reliance on a Single Strategy to Control Infection

WASHINGTON — Health care workers who interact with patients suspected or confirmed to be infected with novel H1N1 influenza A — the new strain of pandemic flu — should wear fitted N95 respirators, which filter better than looser medical masks, to help guard against respiratory infection by the virus, says a new report from the Institute of Medicine.  The report endorses the current U.S. Centers for Disease Control and Prevention guidelines for respiratory protection against this novel flu virus, also commonly referred to as swine flu.  However, wearing N95 respirators should be only one element of workers’ and health care organizations’ infection control strategies, stressed the committee that wrote the report.

While the CDC guidelines and the report’s recommendations are based on the best available information and evidence, scientists do not know to what extent flu viruses spread through the air or whether infection requires physical contact with contaminated fluids or surfaces.  The report calls for a boost in research to answer these questions and to design and develop better protective equipment that would enhance workers’ comfort, safety, and ability to do their jobs.

“Based on what we currently know about influenza, well-fitted N95 respirators offer health care workers the best protection against inhalation of viral particles,” said committee chair Kenneth Shine, executive vice chancellor for health affairs, University of Texas System, Austin, and former president of the Institute of Medicine.  “But there is a lot we still don’t know about these viruses, and it would be a mistake for anyone to rely on respirators alone as some sort of magic shield.  Health care organizations and their employees should establish and practice a number of strategies to guard against infection, such as innovative triage processes, handwashing, disinfection, gloves, vaccination, and antiviral drug use.”

In the event that the new pandemic virus creates a surge of patients during the upcoming flu season, it will be critical to protect health care workers from infection given their central role in treating sick people and lessening the pandemic’s overall impact. 

The Institute of Medicine was asked to evaluate personal protective equipment designed to guard against respiratory infection specifically, and therefore the committee focused on the efficacy of medical masks and respirators.  Studies have shown that inhalation of airborne viruses is a likely route of flu infection, supporting the use of respiratory protection during an outbreak even though it is not clear whether airborne transmission is the sole or main way the disease spreads.

N95 respirators and medical masks cover the nose and mouth.  Although similar in appearance, medical masks fit loosely on wearers’ faces, and respirators are designed to form a tight seal against the wearer’s skin.  If properly fitted and worn correctly, N95 respirators filter out at least 95 percent of particles as small as 0.3 micrometers, which is smaller than influenza viruses, the report notes.

Given the short time frame of this study, the committee was not asked to discuss issues associated with implementing its recommendations, such as costs and supplies, or to assess the impact of other infection control measures, such as vaccination or prophylactic use of antiviral drugs.  However, the committee underscored the importance of using a range of infection control strategies to minimize the chances for exposure and infection for health care workers.

The study was sponsored by the CDC and Occupational Safety and Health Administration.  Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.  The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.  A committee roster follows.

Copies of Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu.  Reporters may obtain a copy from the Office of News and Public Information (contacts listed above). 

#       #       #

[ This news release and report are available at http://national-academies.org ]

INSTITUTE OF MEDICINE

Board on Health Sciences Policy

Committee on Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A

Kenneth I. Shine, M.D. (chair)

Executive Vice Chancellor for Health Affairs

University of Texas System

Austin

M.E. Bonnie Rogers, Dr.P.H. COHN-S, FAAN (vice chair)

Associate Professor of Nursing and Director

Occupational Health Nursing Program

Occupational Safety and Health Education and Research Center

University of North Carolina

Chapel Hill

Gloria Addo-Ayensu, M.D., M.P.H.

Director

Fairfax County Department of Health

Fairfax, Va.

Howard J. Cohen, Ph.D.

Independent Consultant

Guilford, Conn.

Lewis R. Goldfrank, M.D.

Professor and Chair

Department of Emergency Medicine

School of Medicine

New York University

New York City

Sundaresan Jayaraman, Ph.D.

Professor

School of Polymer, Textile, and Fiber Engineering and College of Management

Georgia Institute of Technology

Atlanta

William H. Kojola, M.S.

Industrial Hygienist

Department of Occupational Safety and Health

AFL-CIO

Washington, D.C.

Raina McIntyre, Ph.D.

Head

School of Public Health and Community Medicine

University of New South Wales

Sydney, Australia

Mark Nicas, Ph.D., M.P.H., CIH

Adjunct Professor

School of Public Health

University of California

Berkeley

Peter Palese, Ph.D.

Professor and Chair

Department of Microbiology

Mount Sinai School of Medicine

New York City

Trish M. Perl, M.D., M.Sc.

Professor of Medicine and Pathology

School of Medicine

Johns Hopkins University; and

Director

Hospital Epidemiology and Infection Control

Division of Infectious Diseases

Johns Hopkins University Hospital

Baltimore

Tia Powell, M.D.

Director

Montefiore-Einstein Center for Bioethics

Bronx, N.Y.

Carol Raphael, M.P.A.

President and Chief Executive Officer

Visiting Nurse Service of New York

New York City

INSTITUTE OF MEDICINE STAFF

Cathy Liverman, M.L.S.

Co-Study Director

Tracy Harris, D.P.M.

Co-Study Director

Intro:  “In the MMWR, CDC researchers wrote about the first 36 children that died from the novel virus since last spring; of those, two-thirds had underlying medical conditions like cerebral palsy, muscular dystrophy, asthma, diabetes or cardiovascular problems. Some of the other children who died had bacterial illnesses in addition to this novel influenza, so Frieden cautioned physicians that children who have been treated for fever and return with a high fever should be treated with antibiotics. “  Source:  http://www.pediatricsupersite.com/view.aspx?rid=43457)

Link:  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5834a1.htm

MMWR September 4, 2009 / 58(34);941-947

Surveillance for Pediatric Deaths Associated with 2009 Pandemic Influenza A (H1N1) Virus Infection — United States, April–August 2009

Children aged <5 years or with certain chronic medical conditions are at increased risk for complications and death from influenza (1–3). Because of this increased risk, the Advisory Committee on Immunization Practices (ACIP) has prioritized influenza prevention and treatment for children aged <5 years and for those with certain chronic medical and immunosuppressive conditions (4,5). CDC monitors child influenza deaths through its influenza-associated pediatric mortality reporting system. As of August 8, 2009, CDC had received reports of 477 deaths associated with 2009 pandemic influenza A (H1N1) in the United States, including 36 deaths among children aged <18 years. To characterize these cases, CDC analyzed data from April to August 2009. The results of that analysis indicated that, of 36 children who died, seven (19%) were aged <5 years, and 24 (67%) had one or more of the high-risk medical conditions. Twenty-two (92%) of the 24 children with high-risk medical conditions had neurodevelopmental conditions. Among 23 children with culture or pathology results reported, laboratory-confirmed bacterial coinfections were identified in 10 (43%), including all six children who 1) were aged ≥5 years, 2) had no recognized high-risk condition, and 3) had culture or pathology results reported. Early diagnosis of influenza can enable prompt initiation of antiviral therapy for children who are at greater risk or severely ill. Clinicians also should be aware of the potential for severe bacterial coinfections among children diagnosed with influenza and treat accordingly. All children aged ≥6 months and caregivers of children aged <6 months should receive influenza A (H1N1) 2009 monovalent vaccine when available (6).

Influenza-associated pediatric deaths have been nationally notifiable since October 2004. The CDC case reporting system defines an influenza-associated pediatric death as a death in a person aged <18 years with an illness clinically compatible with influenza and whose influenza is laboratory confirmed. State and local health departments report influenza-associated pediatric deaths using a standardized case report form that collects information on demographics, dates of illness onset and death, location of death, chronic medical conditions, influenza testing, bacteria or fungi cultured from sterile and nonsterile sites, and medical care received during the influenza illness. The case report form provides a list of chronic medical conditions that have been associated previously with an increased risk for complications from seasonal influenza and space to describe additional chronic medical conditions not listed on the form. Results of pathology testing conducted at CDC also are included. Medical records, medical examiner reports, and death certificates were not reviewed.

This case series included data reported to CDC on all deaths associated with laboratory-confirmed 2009 pandemic influenza A (H1N1) virus infection occurring in persons aged <18 years through August 8, 2009. Laboratory confirmation was defined as a positive test for 2009 pandemic influenza A (H1N1) virus by reverse transcription–polymerase chain reaction (RT-PCR). CDC requested supplementary information from state and local health departments on antiviral treatment and chronic medical conditions for deaths associated with 2009 pandemic influenza A (H1N1) virus infection. For this case series, invasive bacterial coinfection was defined as laboratory detection of a bacterial pathogen in a specimen from a normally sterile site or a postmortem lung biopsy. Children were considered at high risk if they were aged <5 years or had one of the medical conditions recognized to increase the risk for influenza-related complications,* based on a review of the available medical data by a developmental pediatrician.

Thirty-six pediatric deaths associated with 2009 pandemic influenza A (H1N1) infection were reported from 15 state and local health authorities† through August 8 (Table 1).§ Illness onsets occurred during May 9–July 20, and deaths occurred during May 15–July 28. Six deaths occurred in May, 25 deaths in June, and five deaths in July. Median age of the patients was 9 years (range: 2 months–17 years); 50% were male, 42% were non-Hispanic white, and 33% were Hispanic (Table 2). Seven (19%) of the 36 children were aged <5 years (five were aged <2 years), and 24 (67%) had at least one high-risk medical condition, including three children aged <5 years. Among the 24 children with high-risk medical conditions, 22 (92%) had neurodevelopmental conditions (e.g., developmental delay or cerebral palsy). Of these 22 children, 13 (59%) had more than one neurodevelopmental diagnosis, and nine (41%) had neurodevelopmental and chronic pulmonary conditions. Eight (22%) of the 36 children were aged ≥5 years with no reported high-risk conditions. Two of these eight children were reported as obese; however, height and weight measurements were not reported.

Duration of illness before death in the 36 cases ranged from 1 day to 28 days (median: 6 days). Among 31 children for whom antiviral treatment data were available, 19 (61%) received antiviral treatment, and four of those received treatment within 2 days of illness onset. Of 25 children for whom information was available, 13 (52%) had received at least 1 dose of the 2008–09 seasonal influenza vaccine, including 11 children with high-risk medical conditions. Of the 23 children with culture or pathology results reported, 10 (43%) had a laboratory-confirmed bacterial coinfection, including Staphylococcus aureus (five, including three methicillin-resistant S. aureus), Streptococcus pneumoniae (three), Streptococcus pyogenes (one), and Streptococcus constellatus (one). Among the eight children aged ≥5 years who did not have a high-risk medical condition, six had a laboratory-confirmed invasive bacterial coinfection, including four with S. aureus; the other two children either had no specimens collected or information regarding bacterial coinfection was unavailable. Among the seven children aged <5 years who died, two had a laboratory-confirmed bacterial coinfection; neither child had a high-risk medical condition.

Editorial Note:

Twenty-eight (78%) of the 36 children whose deaths were associated with 2009 pandemic influenza A (H1N1) virus infection were in at least one of two groups previously found to be at increased risk for complications from seasonal influenza: children aged <5 years and those with a high-risk chronic medical condition (1–3). The percentage of children with high-risk medical conditions (67%) in this series is higher than the percentage reported in recent influenza seasons. During the 2003–04, 2004–05, 2005–06, and 2006–07 seasons, a total of 153, 47, 46, and 73 pediatric deaths were reported through the influenza-associated pediatric mortality reporting system, respectively. During those seasons, the percentages of children with high-risk medical conditions were 47%, 55%, 48%, and 35%, respectively (1,7). During the same seasons, among children who died, the percentages of children aged <5 years and aged <2 years among pediatric deaths was generally higher (<5 years, 42%–63%, <2 years, 26%–46%) than the 19% and 14%, respectively, reported for 2009 pandemic influenza A (H1N1). Continued surveillance is needed to determine whether these and other differences between pediatric deaths from seasonal influenza and deaths from 2009 pandemic influenza A (H1N1) are important.

Notably, among children with high-risk medical conditions, 92% had neurodevelopmental conditions (e.g., developmental delay or cerebral palsy), a finding consistent with the results from a study of influenza-associated mortality during the 2003–04 influenza season (1). In 2005, that finding helped lead to the addition of neurodevelopmental conditions to ACIP’s list of conditions that should prompt seasonal influenza prevention and treatment (8). The findings from this report indicate that most of the children with neurodevelopmental conditions who died had multiple neurodevelopmental diagnoses and/or comorbid pulmonary conditions. Health-care providers should be aware of the potential for severe influenza illness, including death, in these children.

This report also highlights the prominence of laboratory-confirmed bacterial coinfections, which were identified in 10 (43%) of the 23 children who had culture or pathology results reported. All six children who were aged ≥5 years, did not have a high-risk medical condition, and had culture or pathology results reported had an invasive bacterial coinfection, suggesting that bacterial infection, in combination with 2009 pandemic influenza A (H1N1) virus infection, can result in severe disease in children who might be otherwise healthy. Clinicians should be aware of the potential for severe bacterial coinfections among children diagnosed with influenza and treat accordingly. As always, diagnostic testing and susceptibility testing of bacterial isolates are important to guide antibiotic therapy. Empiric antibacterial therapy, when indicated, should be directed at likely pathogens associated with influenza, such as S. aureus, S. pneumoniae, and S. pyogenes (1,7). In addition, all children should be current on recommended vaccinations, including 7-valent pneumococcal conjugate vaccine. Children aged ≥2 years with certain high-risk medical conditions are recommended to receive the 23-valent pneumococcal polysaccharide vaccine in accordance with guidance.¶

Although the majority of children in this case series received antiviral treatment, few received treatment within 2 days of illness onset. Influenza antiviral treatment is recommended for persons with suspected or laboratory-confirmed influenza who are hospitalized or who are at greater risk for influenza-related complications.** If a child is not in a high-risk group or is not hospitalized, health-care providers should use clinical judgment to guide treatment decisions. When evaluating children, clinicians should be aware that the risk for severe complications from seasonal influenza among children aged <5 years is highest among children aged <2 years. Antiviral treatment should be started as soon as possible after illness onset; evidence for benefits from antiviral treatment in studies of seasonal influenza is strongest when treatment is started within 48 hours of illness onset (5). However, treatment of any person with influenza who requires hospitalization is recommended, even if treatment is started >48 hours after illness onset. Health-care providers should be aware that although specificity is high, sensitivity of rapid influenza tests to detect 2009 pandemic influenza A (H1N1) virus infection is low (9); therefore, a negative test result does not exclude 2009 pandemic influenza A (H1N1) virus infection.

The findings in this report are subject to at least five limitations. First, influenza-associated pediatric deaths might be underascertained because of a low level of influenza testing among children or underreporting of diagnosed cases. Second, differences in case ascertainment limit the direct comparability of the findings in this report with findings from reports for seasonal influenza. All patients in this series were identified as having 2009 pandemic influenza A (H1N1) virus infection using RT-PCR, but surveillance for pediatric deaths associated with seasonal influenza includes cases ascertained by various diagnostic tests, some of which are less sensitive than RT-PCR. Third, some chronic medical conditions might be underreported in the case reporting system because they are not specifically listed on the case report form; however, the collection of supplementary data on chronic medical conditions from state and local health authorities might have helped to minimize this potential bias. Fourth, incomplete data on antiviral treatment and testing for invasive bacterial coinfections might have led to some children being misclassified. Finally, because medical records were not reviewed, the severity of neurodevelopmental conditions, including the degree of associated respiratory impairment, could not be characterized.

Vaccination is the primary strategy to prevent influenza and related complications. Persons aged 6 months–24 years and persons who live with or provide care for infants aged <6 months are recommended for vaccination against 2009 pandemic influenza A (H1N1) virus infection (6). Initial doses of influenza A (H1N1) 2009 monovalent vaccine are expected to become available in mid-October. Guidance from CDC regarding administration of vaccine, antiviral treatment, management of influenza-associated bacterial complications, and other prevention and control measures for 2009 pandemic influenza A (H1N1) will be updated as needed. Health-care providers can find current recommendations online at http://www.cdc.gov/h1n1flu.

Acknowledgments

The findings in this report are based, in part, on contributions by A Spacone, MPH, Pima County Health Dept; V Berisha, MD, Maricopa County Dept of Public Health; J Meyer, MPH, Arizona Dept of Health Svcs; V Conte, MD, F Leguen, MD, Miami-Dade County Health Dept; K McConnell, MPH, Florida Dept of Health; P Linchangco, MPH and M Vernon, DrPH, Cook County Dept of Health, Illinois; M Crockett, MPH, N Cocoros, MPH, S Lett, MD, Massachusetts State Dept of Public Health; K Martin, C Lees, C Morin, Minnesota Dept of Health; New Jersey H1N1 Investigation Team; B Copple, Marion County Health Dept; M Vandermeer, R Leman, Oregon Public Health Div; C Browning, T Cooper, MPH, Rhode Island Dept of Health; T Koy, MPH, Texas Children’s Hospital; L Bullion, Texas Dept of State Health Svcs; J Davis, Wisconsin Dept of Health Svcs; and R Olney, MD, and D Anderson-Carr, MPH, National Center on Birth Defects and Developmental Disabilities, CDC.

References

1. Bhat N, Wright JG, Broder KR, et al. Influenza-associated deaths among children in the United States, 2003-2004. N Engl J Med 2005;353:2559–67.
2. Keren R, Zaoutis TE, Bridges CB, et al. Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection. JAMA 2005;294:2188–94.
3. Coffin SE, Zaoutis TE, Rosenquist AB, et al. Incidence, complications, and risk factors for prolonged stay in children hospitalized with community-acquired influenza. Pediatrics 2007;119:740–8.
4. CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR 2009;58(No. RR-8).
5. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR 2008;57(No. RR-7).
6. CDC. Use of influenza A (H1N1) 2009 monovalent vaccine. MMWR 2009;58(No. RR-10).
7. Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics 2009;122:805–11.
8. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2005. MMWR 2005;54(No. RR-8).
9. CDC. Evaluation of rapid influenza diagnostic tests for detection of novel influenza A (H1N1) virus—United States, 2009. MMWR 2009;58:826–9.

* Additional information available at http://www.cdc.gov/h1n1flu/identifyingpatients.htm.

† Arizona (six cases), California (three), Connecticut (one), Florida (one) , Illinois (two), Massachusetts (one), Minnesota (two), New Jersey (three), New York (four), New York City (four), Oregon (one), Rhode Island (one), Texas (two), Utah (three), and Wisconsin (two).

§ A total of 33 cases were reported to CDC through August 8, 2009, and published online in FluView (http://www.cdc.gov/flu/weekly/fluactivity.htm). However, an additional three cases that were subject to reporting delays were added, bringing the total to 36.

¶ Additional information at http://www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm.

** Additional information available at http://www.cdc.gov/h1n1flu/recommendations.htm.