Flu Wreaking Havoc on Hospitals, Infection Control Practices Struggling

As the United States continues to battle a rough influenza season, the precarious situation has illuminated gaps in how we prepare and respond to infectious disease threats. The Centers for Disease Control and Prevention (CDC) reported that for the week ending in January 13, 6.3% of individuals who saw their health care provider did so for influenza-like illness (ILI). A total of 7 additional pediatric deaths were reported last week as well, bringing the case count up to 37. Current ILI numbers are similar to those seen during the 2009 swine flu pandemic.

Hospitals are being hit hard by a rapid influx of individuals who are requiring isolation, treatment, and manpower during a time where health care institutions are already suffering from an intravenous (IV) bag shortage. I’ve seen some hospitals go on diversion because they are so inundated with patients that they are unable to accept any more. Hospitals are experiencing shortages of influenza testing kits, conference rooms and outside tents are being set up as triage/waiting areas, personal protective equipment (PPE) stores are being strained. Furthermore, infection prevention and control practices are being stressed against the influx of patients and staff calling in sick. All the while, clinicians are trying to maintain proper isolation precautions.

Many health care experts have pointed to these struggles as a sure sign that should an influenza pandemic occur at proportions seen during the Spanish flu pandemic of 1918-1919, we will not be able to manage at a health care level.

To add insult to injury, a recent study on the transmissibility of aerosols and the role they play in spreading influenza has uncovered some disheartening results.

In infection prevention, influenza (seasonal) patients are put on droplet precautions, which means they are given a surgical mask to wear to mitigate the transmission of any influenza droplets that are coughed or sneezed out upwards of 3 feet into the air. Surgical masks are effective against larger droplets that are coughed/sneezed, but not smaller ones that are transmitted through aeorosolization.

This recent study found, however, that there is “overwhelming evidence that humans generate infectious aerosols and …that sneezing is rare and not important for—and that coughing is not required for—influenza virus aerosolization.” The investigators monitored participants for 30 minutes to capture samples during coughing, sneezing, and speaking. During this time, they collected 218 nasopharyngeal samples and 218 breathing samples. They looked at aerosols that were coarse and fine and found that a surprisingly large group of individuals shed the finer aerosols (airborne transmissible) and of these fine aerosols, nearly half were shed when the patient was just breathing (ie, not coughing). This is a departure from the long-held belief that we only shed the lighter (finer) aerosols when coughing or sneezing.

Although enhanced respiratory protection measures (ie, the use of an N-95 mask) are currently only recommended for cases of avian influenza A (H7N9, Asian H5N1) and a novel influenza A virus that is not circulating in humans with severe disease, given this recent study, it begs the question if we should also be using enhanced isolation for seasonal flu or at least the kind that causes severe disease. The study results point to the need for additional research into aerosol transmission of seasonal flu and the capacity for people to spread it, through aerosols, without coughing and/or sneezing.

Perhaps the biggest challenge though, is consistent hand hygiene and isolation precautions. It’s easy to focus on pandemic preparedness and enhanced isolation precautions during emergencies, but we all know that it is at those times that basic infection prevention and control measures (ie, hand hygiene) tend to go out the window as we scramble to care for patients. However, until we are able to practice perfect infection control technique with every patient, every time, it is unlikely that we will ever be able to handle more complex pandemics. The severity of this flu season and the struggles that American hospitals are experiencing should be a wake-up call not just for pandemic preparedness, but also for strengthening our basic prevention and response practices. Now is the time to perfect our processes and skills, so it becomes second nature to get ILI patients masked rapidly in the waiting areas, ensure staff use PPE continuously and correctly, and practice thorough hand hygiene while keeping the environment clean. Only then will we have any hope of handling “the big one” if and when it occurs.