Non-Pharmaceutical Interventions and Our Children

Community Mitigation Strategies

What are non-pharmaceutical interventions or NPI’s?

NPI’s are considered to reduce exposure of susceptible persons to an infectious agent. They were commonly used interventions for infection control in years past. There has been much discussion as to their effectiveness especially when dealing with the spread of influenza because the incubation period is short and it is easily mistaken, at onset, to many other illnesses.

http://www.pandemicflu.gov/plan/community/community_mitigation.pdf

In the case of pandemic influenza, the appearance of signs and symptoms would dictate that an assumption towards a cautious attitude be made. Also, as in the case of pandemic influenza people may transmit infection asymptomatically for 24 to 48 hours allowing people to unknowingly infecting others including family members. Influenza is spread mainly by droplet transmission, but it also can be spread by direct and indirect contact transmission or by airborne transmission.

The effectiveness of NPI’s in limiting the spread of pandemic influenza depends on the transmission characteristics of the novel virus. If most of the transmission occurs during the incubation period or during asymptomatic infection, the effectiveness of NPI use will be diminished, unless we start using these tools prior to the first cases showing up in the US, not likely. The age range of the affected patients is also important in determining the effectiveness of NPI’s. If children are the initial spreaders in the community, school closure would be more effective. The novel pandemic influenza subtype may be quite different than that which we are seeing now. Because a new subtype might have different transmission characteristics and these characteristics and associated illness patterns we must remain flexible and open to changing our approaches in limiting the spread of this disease.

So, short of living in a bubble for the next 2 years, with several waves passing through our communities, how do we lessen the viral loads in our environment while continuing to live our lives? Is this even possible? Certainly, at some point in time, we are all going to have to come in contact with this bad bug.

There will be no vaccines for 6 months with egg-based production and 3 months for the initial doses of a new reverse genetics production technique. Another post for another day: the ethics of vaccine production and distribution.

Because we want to protect ourselves and our children from this and pharmaceutical interventions like vaccines, anti-virals (such as Tamiflu and Relenza) and Flumist, may not be widely available. And because these all deserve their own discussion due to side effects and ethical considerations, we need to discuss other methods of protection for our families.

Some of the NPI’s that have been suggested to possibly have an impact the spread of pandemic influenza are social distancing, early school closure in an effected area, disinfection measures, infection barriers, and business closures. The problems that stem from utilizing these interventions are mind-boggling. Who pays us when we can’t work because our children cannot go to school? What will happen to the children who need the school system for some of their basic care? Who will supply the barrier measures like masks and gloves? How will I know as an individual or a parent when to implement these measures?

Since the government has stated repeatedly that “you are on your own”, we must be about solving some of these issues for ourselves. No one is going to safeguard your family, no one is going to supply you with masks, gloves, goggles, food, water, medicine….you are truly on your own.

Fortunately, there is plenty of information out there for people who diligently search for it. Because the surge capacity for our local hospitals is surprisingly low, most of us will not have access to medical care within 48 hours of an outbreak in our area. That means that we will have to self isolate, quarantine — and care for our loved ones at home during the illness. Since pandemic influenza is a deadly disease, some estimate the case fatality rate as being anywhere from 2.5% on up to the current estimate of 80%. Even a catastrophic rate of 5% would drastically alter the course of our society. It is always good to remember what we are dealing with when we talk about a novel influenza strain affecting humans.

from Wikipedia … “The Pandemic Severity Index (PSI) is a proposed classification scale for reporting the severity of influenza pandemics in the United States. The PSI was accompanied by a set of guidelines intended to help communicate appropriate actions for communities to follow in potential pandemic situations. Released by the United States Department of Health and Human Services (HHS) on February 1, 2007, the PSI was designed to resemble the Saffir-Simpson Hurricane Scale classification scheme”

I found this on Fluwiki today…this is not your typical flu.

This is an excerpt from John Barry’s book “The Great Influenza” (Chapter Title: Tolling of the Bell; Hardcover pp 361-362):

“On the opposite edge of the continent the story was the same. In Labrador man clung to existence with tenacity but not much more permanency than seaweed drying on a rock, vulnerable to the crash of surf at high tide.

The Reverend Henry Gordon left the village of Cartwright in late October and returned a few days later, on October 30. He found “not a soul to be seen anywhere, and a strange, unusual silence.” Heading home, be met a Hudson’s Bay Company man who told him “sickness…has struck the place like a cyclone, two days after the Mail boat had left.” Gordon went from house to house. “Whole households lay inanimate on their kitchen floors, unable even to feed themselves or look after the fire.” Twenty-six of one hundred souls had died. Further up the coast it was worse. Of 220 people at Hebron, 150 died. The weather was already bitter cold. The dead lay in their beds, sweat having frozen their bedclothes to them.

Gordon and some others from Cartwright made no effort to dig graves, consigning the bodies to the sea. He wrote “A feeling of intense resentment at the callousness of the authorities, who sent us the disease by mail-boat, and then left us to sink or swim, filled one’s heart almost to the exclusion of all else….”

Then there was Okak. Two hundred sixty-six people had lived in Okak, and many dogs, dogs nearly wild. When the virus came it struck so hard so fast people could not care for themselves or feed the dogs. The dogs grew hungry, crazed with hunger, devoured each other, and then wildly smashed through windows and doors, and fed.

The Reverend Andrew Asboe survived with his rifle beside him; he personally killed over one hundred dogs. When the Reverend Walter Perret arrived, only fifty-nine people out of 266 still lived.

….In all of Labrador, at least one-third the total population died.”

…Many thanks to Into The Woods for posting this on the wiki

Now that we have had that sobering reminder the following is adapted from information from the Health Protection Surveillance Center of Ireland http://www.hpsc.ie/hpsc/

You should seek medical care if the sick person develops any of these symptoms:
• Has increasing shortness of breath
• Gets pain in the chest or ribs when breathing or coughing
• Has a cough producing phlegm or spit
• Rapid Heart rate (≥ 120 per minute in adults)
• Has rapid breathing and/or wheezing
• Still has a fever and not feeling better after 5 days
• Starts to feel better and then suddenly develops a fever again
• Looks drowsy or confused /disorientated

In children and babies, other signs of complications can include: • Difficult or noisy breathing (particularly a grunting sound when breathing)
• Rapid breathing (more than 50 breaths per minute)
• Difficulty feeding
• Not drinking enough or vomiting for more than 24 hours
• Severe ear ache
• More drowsy than usual
• Crying inconsolably
• Pale, blue-tinged, cold or mottled hands and feet
• A rash
• Getting worse instead of better
Preventing infection spreading in the home
• Hand washing is important
• The most important way to prevent transmission of influenza to others is hand washing. Flu virus can survive on hands for 5 minutes, and is removed by washing hands in warm soapy water.
• The person caring for the sick person (caregiver), the sick person, and others in the household should wash their hands frequently using soap and warm water.
• The caregiver should wash his/her hands immediately before and after providing care to the sick person.
• Plain soap may be used for hand washing. Soaps containing antiseptics are not required. Bar soap should be stored so that it dries after use.
• A waterless antiseptic hand rinse can be used if hand-washing facilities are not accessible.
• The caregiver does not need gloves, gowns or aprons when caring for the sick person, but should wear a mask
• Caregivers should ensure that any open skin lesions, cuts etc on their arms or exposed skin are covered with a dry dressing at all times

Care for the sick person on their own (isolation)
• If possible only the caregiver should stay with them.
• The sick person should stay in one room with the door closed and windows open (weather permitting).
• Other family members should stay away from the sick person and not handle or share items such as dishes, books, toys or other items that the sick person has used unless it has been washed thoroughly with soap and water or regular household clearing product.
• Ideally the sick person should use a separate bathroom and towels to the rest of the family.
• Discourage visits from persons not living in the household, and do not let them enter the house.

Wear masks
• The caregiver should wear a surgical mask.
• The sick person should wear a surgical mask if other persons are in their room, or if they leave their room.
• The sick person should cover his/her mouth when coughing or sneezing and wash his/her hands immediately afterwards
• Avoid touching the eyes with hands to prevent self-contamination with flu virus
How to keep things clean
• The sick person’s bed sheets; towels and clothes can be washed with items from other household members, preferably in warm water. A washing machine can be used.
• The sick person’s laundry should not be left sitting outside the room e.g. in a laundry basket where others could become exposed to it
• Used tissues should be put by the ill person directly into a rubbish bag which can be sealed in the room and taken directly outside by the care provider for collection with regular rubbish.
• Surfaces and items inside the sick person’s room should be cleaned with regular household cleansers.
• Items handled by the sick person, including cutlery and glasses, should be cleaned by the care provider (or in a dishwasher) immediately upon removal from the sick persons room. Universal Respiratory Etiquette
The following are components of a universal respiratory etiquette strategy to be adopted in all health care facilities.
The posting of visual alerts at the entrances to all healthcare facilities, instructing patients and those who accompany them to:
• Inform healthcare personnel of symptoms of a respiratory infection when they first register for care
• Practice respiratory etiquette
• Advise visitors with respiratory symptoms to defer their visit until symptoms have resolved
• All patients and visitors who have symptoms of an infectious respiratory illness (cough, runny nose, sore throat or sneezing) should be provided with a surgical mask and instructions on their proper use and disposal. They should also be provided with instructions on hand-hygiene.
• For those who cannot wear a mask, provide tissues and instructions on when to use them (i.e. when coughing, sneezing, or controlling nasal secretions), where they should be disposed of, and on the importance of hand-hygiene after using them
• Waste bins should be readily available for disposal of tissues.
• Provide hand-hygiene materials in the waiting room areas and encourage persons with respiratory symptoms to perform hand-hygiene
• Instruct registration, reception and triage staff of their risk of exposure to infections spread by droplets and to consider wearing masks whenever registering or assessing patients who have respiratory symptoms and are not wearing a mask. Instruct them to remain at least 3 feet from unmasked patients.
• Consider the use of Plexiglas barriers at the point of triage or registration to protect healthcare personnel from contact with respiratory droplets.
• Where possible, designate an area, cubicle or separate room in waiting areas where patients with respiratory symptoms can be segregated (ideally by at least 3 feet) from others without respiratory symptoms.
Commonly used surfaces such as door handles, handrails, table surfaces etc. should be cleaned twice daily with disinfectant.
• Use droplet precautions to manage patients with respiratory symptoms until it is determined that the cause of the symptoms is not an infectious agent that requires more than standard precautions.

Guidance for schools
The following guidance outlines steps, which should be undertaken by schools during a pandemic and advice on how to reduce the spread of infection. The general principles outlined for schools below should be adapted also for use in the workplace.
• Schools should have a school closure contingency plan in place if school closure becomes necessary
• Any employee, teacher, student or staff suspected of having flu should not attend school
• Wash hands several times a day using soap and warm water for 15-20 seconds. Dry hands with paper towels or automatic hand dryers if possible. In school, allow regular breaks for the students and teachers to wash their hands. Young children should be instructed and assisted to ensure proper hand washing. Bathrooms and toilets should be checked regularly to ensure that soap and paper towels are always available.
• The flu can be spread from coughs and sneezes. Make sure tissues are available in all classrooms. Students and staff should cover their mouths when coughing and use a tissue when sneezing or blowing their noses. Tissues should be thrown away immediately followed by proper hand washing (alcohol hand gels may be used in the classrooms to minimize disruption)
• Schools may be required by their local Department of Public Health to report absences due to flu when they reach a locally determined number. Reporting outbreaks assists in surveillance and understanding impact in the community
• Schools should be extra vigilant that ill students be excluded from sports activities, choir or other activities that may involve close contact, since transmission may be easier in these situations. All students and staff should avoid sharing glasses, water bottles, drinks spoons/forks etc.
• School buses, because of the enclosed space, may allow for easy spread of the flu. Tissues should be available on the buses, and students should be encouraged to cover nose and mouth while coughing or sneezing. Disinfect commonly handled interior surfaces (i.e. door handles, hand rails etc) between loads of students if possible
• In the school, clean commonly used surfaces such as door handles, handrails, eating surfaces, desks etc frequently with disinfectant (bleach solutions or commercial disinfectants are appropriate)