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362 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

35
and vomiting. The disease spread globally with millions for most hospitals and health services and to reduce the
of cases reported and resulted in over 16,000 deaths by risk of nosocomial influenza in hospitals. 40
March 2010. 38
ISOLATION PRECAUTIONS AND PERSONAL
Australia and New Zealand communities had a high pro-
portion of cases of H1N1 influenza-A infection, with 856 PROTECTIVE EQUIPMENT
patients being admitted to ICU; 15 times the incidence Key aspects of infection control in an epidemic or pan-
of influenza A in other recent years. Infants (aged 0–1 demic situation focus on limiting opportunities for noso-
years) and adults aged 25–64 years were at particular risk; comial spread and the protection of health care workers.
others at increased risk were pregnant women, adults Guidelines for institutional management of these infec-
with a BMI over 35 and indigenous Australian and New tions involve designing and implementing appropriate
Zealand populations. Australian and New Zealand Inten- isolation procedures and recommending appropriate
sive Care Society (ANZICS) investigators prepared a personal protective equipment (PPE). The impor-
report based on the Australian and New Zealand experi- tance of adequate PPE was highlighted particularly in
ence to assist those in the northern hemisphere to better the SARS epidemic where there was overrepresentation
prepare for their winter influenza season. 39 of health care workers who became patients infected
with the virus. 35
The emergence of novel swine-origin influenza A virus
was not anticipated and it is unlikely, given the limita- Specific infection control guidelines are usually devel-
tions of current knowledge, that future pandemics can be oped for individual institutions, based on government
predicted. The threat of pandemic disease from avian recommendations for management of staff, appropriate
influenza remains high with the rapid evolution of H5N1 PPE and isolation procedures. Table 14.7 summarises
41
viruses; however the direction this will take is unpredict- the recommendations from the Australian and New
42
able. Priorities for prevention and management of future Zealand governments.
influenza pandemics therefore involve development of In all settings, it is important to ensure that staff members
an international surveillance and response network for are familiar with respiratory protection devices. In areas
early detection and containment of the disease, local or situations where respirators (P2 or N-95 masks) are
preparation for controlling the spread of the infection used, a fit-testing program ensures understanding of how
and further development of vaccines and antiviral the devices work and maximal safety. During the SARS
agents. 38
epidemic, infection of staff members through inappropri-
Influenza Vaccinations ate or ineffective use of these masks occurred, and infec-
tion due to failure to wear adequate eye protection was
Influenza vaccines are formulated annually based on also reported. 43
current and recent viral strains. Success in protecting an
individual against influenza requires that the virus strains ACUTE LUNG INJURY
included in the vaccine are the same as those currently
circulating in the community. Vaccines are commonly Acute lung injury (ALI) is a generic term that encom-
effective in 70–90% in preventing influenza in healthy passes conditions causing physical injury to the lungs.
adults younger than 65 years of age. Efficacy appears Acute respiratory distress syndrome (ARDS) is a severe
lower in elderly persons. Health care workers are a key form of ALI as a result of bilateral and diffuse alveolar
target group for the influenza vaccine, at the very least to damage due to an acute insult, and is the predominant
reduce absenteeism over what is often the busiest period form of ALI observed in ICU. 6

TABLE 14.7 Recommendations for personal protective measures in respiratory pandemics

Section Protective measure
Staff management Assessment of staff at increased risk of complications from the specific infection should be
redeployed if possible
Monitoring health care workers for signs of illness and management with antivirals as a priority
Personal protection: basic measures Hand hygiene, social distancing, safe cough/sneeze etiquette, and good ventilation
Personal Protective Equipment Gloves
Gowns/aprons
Eye protection
Masks: a range of masks are available to provide respiratory protection to workers in medium to
high-risk situations. Two options are available:
● Surgical mask: designed to contain droplet spread from the wearer but offers a degree of
protection from external infection
● P2 or N-95 particulate masks: provide a higher degree of filtration or respiratory protection,
when appropriately worn and handled