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Respiratory virus season is upon us, and the influenza activity in Australia, which is usually a predictor, has left many experts in a state of worry. In the face of a flu and respiratory virus season of unknown severity, infection prevention efforts turn to tried and true processes. Isolation precautions, use of personal protective equipment (PPE), and vigilant hand hygiene are all strategies we stress not only during the winter months, but also during outbreaks.
As many hospitals begin administering flu vaccinations to healthcare workers and ensuring they have enough masks and gowns, there are some new studies infection prevention teams should be aware of. Moreover, by discussing the latest in literature, those on the frontlines can benefit from lessons learned from past flu seasons and outbreaks of measles and respiratory syncytial virus (RSV) alike.
Leveraging PPE to Fend Off Infection
One of the first steps we in infection prevention and control can take is to reinform staff that patients entering into the healthcare facility with signs and symptoms (fever, cough, runny nose, aches) should be isolated quickly, and PPE should be used. Sure, the symptoms could stem from allergies, but why take the chance? Would you really take those odds as you check a patient’s vitals and they are coughing and sneezing in your face?
There have, of course, been conversations about what kind of PPE is best: surgical mask or N95 respirators? For influenza, surgical masks are the staple, but many still wonder why N95s are not used, considering they are suggested for the prevention of avian influenza or pandemic influenza. But a new study published in the Journal of the American Medical Association has assessed this very question-would N95 mask usage be more effective in preventing influenza infection1 in healthcare workers? Although this is in an outpatient environment, the study shed light on the risk between both masks, ultimately finding that there was no significant difference in the incidence of laboratory-confirmed influenza. This study is particularly helpful not only in reminding staff that surgical/medical masks are just as effective, but also in reminding them that if they are vigilant in their usage, they will reduce the chances of acquiring influenza during patient care.
Since many healthcare workers dislike wearing N95 masks due to discomfort or trouble finding their designated size, this is a good reminder that surgical masks are effective-and workers should feel confident in their usage.
From the infection preventionist perspective, it’s clear that when healthcare workers wear unnecessary PPE (such as using an N95 for a patient with influenza), yet their colleagues wear the correct PPE, it often confuses the patient and visitors.
Going Hard on Hand Hygiene
The second critical aspect of reacting to respiratory season is one that we all know well but often fall short on: hand hygiene. Studies have placed American healthcare compliance at woefully inadequate rates, slumping to 26% in intensive care units (ICUs) and 36% in non-ICUs.2
Alcohol-based hand sanitizer has been a game changer in healthcare and infection prevention, but it’s easy to forget that washing with soap and water is also important. I tend to tell staff that for every 5-7 times they use hand gel, they should wash their hands well with soap and water to get rid of bioburden and spores that can be removed only through the friction of scrubbing.
Interestingly, a new study3 has also shed light on the efficacy of alcohol-based hand sanitizer against influenza. Investigators found that the efficacy of the hand gel against influenza A virus in mucus was significantly reduced when compared with the virus in saline. Despite 120 seconds of using the hand gel, the influenza A virus remained in mucus, although it was completely inactivated within 30 seconds with saline. Ultimately, alcohol-based hand sanitizer required more time to inactivate influenza A virus in mucus while still moist, but it was wholly effective in 30 seconds when the mucus was dried. Antiseptic hand washing inactivated the influenza A virus within 30 seconds when the mucus was dried. So, what exactly does this mean? If a healthcare worker’s hands carry infectious mucus that has not completely dried, it poses a risk for decreased hand gel efficacy, at least for influenza A.
But What About Sick Patients?
We can emphasize proper PPE and hand hygiene-which are, of course, critical-but those efforts alone are not enough. It is also vital that rapid identification and isolation of potentially infectious patients occur. Too many times, a patient with a cough is not handed a mask while they wait in the emergency room lobby, or a child with a severe cough is not placed in proper isolation. These situations can pose a risk for healthcare workers and visitors alike.
Many hospitals offered heavily emphasized measles education and encouraged prevention efforts this past year as outbreaks surged across the country. Leaders behind these specialized efforts should also see respiratory virus season as a prime time to home in on the infection prevention skills we let fall during “slow” seasons. Maintaining the vigilance of rapid identification and isolation of patients with concerning symptoms is a skill that serves during both flu season and times of vaccine-preventable disease outbreaks.
In its latest infection prevention guidance for measles in healthcare, the US Centers for Disease Control and Prevention (CDC) highlighted the importance of rapidly identifying and isolating patients with known or suspected measles. The CDC also advised hospitals to routinely promote and facilitate respiratory hygiene and cough etiquette. Unfortunately, I have seen the outcome of delayed isolation. Whether it be measles, RSV, or even pertussis, it has caused significant disruption and burden to not only patients and their families, but also nursing and infection prevention staff. If we maintain a consistent level of education and effort to ensure that staff prepare for and respond to infectious diseases, regardless if they are seasonal or vaccine-preventable, it becomes a habit and not a task.
Act Now to Fight the Flu
Too often, influenza season is approached with the ominous expectation of exhausted healthcare workers and the risk of disease transmission. Perhaps, though, if we approach flu season with the same vigor as an outbreak of measles, we can maintain a level of compliance and vigilance. In the face of potentially severe influenza season and new findings in the literature, we should emphasize hand hygiene (washing and gel), confidence in PPE, and rapid isolation of patients who might have a respiratory infection. We have the tools and the knowledge, but now is the time to act.
Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in Biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities.
1. Radonovich LJ, Simberkoff MS, Bessesen MT, et al. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial. JAMA. 2019;322(9):824–833. doi:10.1001/ jama.2019.11645
2. Mcguckin M, Waterman R, Govednik J. Hand Hygiene Compliance Rates in the United States-A One-Year Multicenter Collaboration Using Product/Volume Usage Measurement and Feedback. American Journal of Medical Quality. 2009;24(3):205- 213. doi:10.1177/1062860609332369
3. Hirose R, Nakaya T, Naito Y, et al. Situations Leading to Reduced Effectiveness of Current Hand Hygiene against Infectious Mucus from Influenza Virus-Infected Patients. mSphere. 2019;4(5). doi:10.1128/msphere.00474-19