Guidelines for Employees with member contact
H1N1 and Seasonal flu

H1N1 and Seasonal flu look the same.  But H1N1 is more likely to be severe in young adults, while seasonal flu is more likely to be severe in older adults. Complications with H1N1 occur more often in younger adults, while older adults are more likely to experience complications with seasonal flu.

Since you can’t tell whether a flu-like infection is H1N1 or seasonal flu, you have to approach it as if it could be either type of flu. The precautions, treatment, infection control measures and prophylaxis plans are based on seeing a flu-like illness, regardless of which it is.
The hallmark symptom is fever. Just a cough alone without fever is unlikely to be flu. Other typical flu symptoms are sore throat, congestion, cough and muscle aches. Occasionally, people will have nausea or vomiting in addition.

The main things to think about are: diagnosis, treatment and infection control.

For FAQs about H1N1 for employees with member contact click here.

Lab Testing:

The CDC is recommending that you not get tested for H1N1; it may put others at risk. If you have flu-like symptoms, call it flu and proceed accordingly. Since both H1N1 and regular flu are likely to be in the community this fall, a lab test is not needed to know it may be H1N1. Knowing which flu you may have doesn’t change your management in terms of infection control or treatment.

Anti-Viral Treatment:

There is no evidence that treatment with oseltamivir decreases the risk of complications for either seasonal flu or H1N1. The highest risk for hospitalizations is among children younger than five, followed by people ages 5-24. Older adults are at decreased risk for complications from H1N1 than these younger groups. Treatment, if started within 48 hours, does little to decrease the duration or severity of the disease. The facts are:

• Treatment is of no benefit if started after 48 hours.
• Treatment doesn’t affect the guidelines about when a person returns to work.
• Treatment doesn’t reduce the risk of complications (i.e. pneumonia, asthma exacerbations).
  

Therefore we do not recommend treatment as a general rule.  Policy from the place where the ill person resides or recommendations from the primary care provider may supercede however.
Primary treatment is supportive, with use of Tylenol, fluids, cough suppressant, etc. as needed.

Infection Control

The mainstay of infection control is reducing transmission. This is accomplished by:

1. Staff should hand-wash after caring for a person.
2. Staff should avoid touching their eyes, nose and mouth after being in a residence/facility or after caring for a person until after they’ve washed their hands.
3. Our staff should wear a fitted N-95 FFP mask when caring for any member with active flu-like symptoms. This would refer to Partnership and Family Care team members, Home Care, Day Center, Rehab, Dental and Transportation staff.
4. Reduce/postpone any non-essential member visits to providers' offices during the time the member is symptomatic.
5. Reduce/postpone any non-essential staff visits to members' residences, when the member has flu-like symptoms. If staff has to make a visit, the risk of exposure should be very low if the staff member wears a mask, washes hands, and avoids touching mouth, nose and eyes. 
6. If there is another person ill with flu at the member's residence, and he or she can’t be “socially isolated”, (i.e. removed about one meter from where the Care Wisconsin staff will be working) then the visit to the member should be reduced/postponed if non-essential.
7. If a family member of one of our members gets the flu, then the family member should socially isolate, wash her or his hands often and wear a surgical mask, as much as possible.
8. Members on the bus or in the Day Center should wear a surgical mask if coughing or feverish. 
9. With members who attend the Day Center, teams should work with families to create a back-up plan for when a member gets sick and can’t go to the Day Center or needs to be sent home from the Day Center on short notice.
10. Members who feel sick with flu-symptoms should stay home for seven days after symptom onset, or until 24 hours post symptoms, whichever is greater. At home, members who have flu-symptoms should stay in their own area and not the common area until not symptomatic. They should wash their hands often and should wear surgical masks if possible when they will be in close proximity to others.
11. For members in CBRFs who develop flu-like symptoms, the team should alert CBRF staff to take infection control precautions (i.e. hand-washing, use of fitted masks rather than surgical masks for staff, etc.) as soon as possible. 
    

The N-95 Mask

The N-95 FFP mask should be placed in a paper bag after use and marked with the user’s name to avoid re-use by another person. The N-95 FFT may be re-used until it is visibly soiled, torn or damaged, until it becomes moist from condensation of exhaled air, or until the user can no longer get a good fit when doing a fit check. Wash your hands after you put away your mask.

Anti-Viral Prophylaxis:

Prophylaxis for flu consists of taking anti-viral medication after a significant exposure, but before the illness starts, to decrease the likeliness of flu developing. Prophylaxis with anti-viral medicine has been shown to significantly reduce the risk of having symptomatic seasonal influenza (and is presumed to decrease the risk of H1N1). Post-exposure prophylaxis may be indicated for members who have been significantly exposed to flu, either through exposure at their place of residence or through exposure at the Day Center or other place where they spend a significant amount of time in a closed space. Prophylaxis must be started with within 48 hours of exposure in order to have a chance of being effective.

It is important to realize the transmission of H1N1 in households is not that high; the transmission rate has been up to 18%, which is slightly lower than that of seasonal influenza. The use of oseltamivir (Tamiflu) reduces transmission rate up to 8%, but carries risk for side effects with one in 20 children taking oseltamivir having the side effect of vomiting.

The primary routes of transmission are:

1. Breathing in aerosol droplets while in a close proximity to an ill person. Aerosol droplet count goes down significantly after a meter distance, so by close proximity, we mean within one meter or so. Wearing a mask reduces the number of aerosol droplets you breathe in when you are within that one meter range. 
2. Touching the virus with your hands on doorknobs, chair arms, counters, and then touching your hands to your mucous membranes (eyes, nose or mouth). This is the main mode of transmission. During flu season, it’s important to avoid touching your eyes, nose or mouth. Hand washing frequently (especially before you intend to touch your eyes, nose or mouth), and washing down surfaces such as doorknobs, counters and chair arms with disinfectant all help to reduce the transmission. 

The day before a person comes down with flu symptoms they may be breathing out aerosol droplets with virus, so there is a risk of transmission. However, the viral load is not as high at that time as when a person is symptomatic, so while there is a risk of infection it is not as high as the first few days a person has symptoms. We consider that a person may significantly transmit viral droplets starting a couple hours before the signs of flu develop.

As a rule of thumb, once persons are no longer symptomatic, they are not transmitting the virus.

Anti-Viral Prophylaxis for Members:

Anti-viral prophylaxis for members may be considered by the teams on a case-by-case basis.
Factors to think about when considering anti-viral prophylaxis:

• How high was the exposure? 
  Exposure would not be considered severe if the ill member was wearing a mask, or if the ill member was sitting more than a meter away. It's important to adhere to basic techniques such as hand sanitizing for all members when they enter the Day Center and periodically while they’re at the Day Center.

Family providers and CBRF staff should tell the team when someone in a member’s residence comes down with flu-like symptoms.  The team should determine the member’s risk for severe illness and the degree of exposure and then decide if they would recommend prophylaxis for the member. The team should educate the member about how to minimize transmission risk. 

In the nursing home, in the absence of a nursing home policy, consider anti-viral prophylaxis for a member if their roommate has flu and cannot be moved to a separate room.

Prophylaxis consists of oseltamivir 75 mg once a day for 10 days. Prophylaxis needs to be started within 48 hours of exposure to be effective.

Prophylaxis of staff:

If a staff member is in a high risk group (i.e. has asthma or other chronic pulmonary disease; cancer; cardiovascular disease; diabetes; pregnancy; weakened immune system; or kidney, liver or neurological disorder), he or she may want to consult with his or her physician regarding prophylaxis. For prophylaxis to be effective, the health care worker will need to get prophylaxis within two days of exposure.

Notifying providers outside of Care Wisconsin:

When the team hears about a member with flu-like illness, the team should notify any external agencies which provide care, such as home care, that there is high risk for significant exposure.