Novel H1N1 Influenza Preparations for Medical Schools and Students

UPDATE - OCTOBER 14, 2009

SUBJECT: Updated H1N1 guidance relevant to medical schools

On October 14, 2009, the Centers for Disease Control and Prevention released updated Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel, available at: http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

The following recommendations from the updated guidance are particularly relevant to medical schools. "Healthcare personnel" are defined as "all persons whose occupational activities involve contact with patients or contaminated material in a healthcare, home healthcare, or clinical laboratory setting," and includes medical school students and other trainees in clinical settings, faculty, and staff.

Monitor and Manage Ill Healthcare Personnel

• Healthcare personnel who develop fever and respiratory symptoms should be instructed not to report to work, or if at work, to promptly notify their supervisor and infection control personnel/occupational health.
  
  
• Healthcare personnel who develop a fever and respiratory symptoms should be excluded from work for at least 24 hours after they no longer have a fever without the use of fever-reducing medications. If healthcare personnel are returning to work in areas where severely immunocompromised patients are provided care, considered for temporary reassignment or exclusion from work for 7 days from symptom onset or until the resolution of symptoms, whichever is LONGER. Clinical judgment should be used for personnel with only cough as a symptom, since cough after influenza infection may be prolonged and may not be an indicator of viral shedding. Healthcare personnel recovering from a respiratory illness may return to work with immunocompromised patients sooner if absence of 2009 H1N1 viral RNA in respiratory secretions is documented by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR).
  
  
• Healthcare personnel who develop respiratory symptoms WITHOUT fever should be allowed to continue or return to work unless assigned in areas where severely immunocompromised patients are provided care. In this case they should be considered for temporary reassignment or exclusion from work for 7 days from symptom onset or until the resolution of symptoms, whichever is LONGER. Clinical judgment should be used for personnel with only cough as a symptom, since cough after influenza infection may be prolonged and may not be an indicator of viral shedding. Healthcare personnel recovering from a respiratory illness may return to work with immunocompromised patients sooner if absence of 2009 H1N1 viral RNA in respiratory secretions is documented by rRT-PCR. " Healthcare personnel should not require a doctor's note to validate their illness or to return to work.
  
  
• Establish non-punitive policies that encourage or require ill health care personnel to stay home.
  
  
• Consider offering alternative work environments as an accommodation for employees at higher risk for complications of 2009 H1N1 influenza during periods of increased influenza activity or if influenza severity increased.
  
  
• Healthcare personnel should perform hand hygiene frequently, including before and after all patient contact, contact with respiratory secretions, and before putting on and upon removal of PPE.
  
  Promote and administer the 2009 H1N1 influenza and seasonal influenza vaccines
  
  
• Healthcare and emergency medical services personnel are among the priority groups recommended to receive the 2009 H1N1 influenza vaccine. To improve adherence, vaccination should be offered to healthcare personnel free of charge and during working hours. Vaccination campaigns with incentives such as lotteries with prizes should be considered. Healthcare facilities should require personnel who refuse vaccination to complete a declination form. The Veterans Health Administration Influenza Manual is a useful source of information on best practices and strategies for increasing immunization rates. (See pp. 21-50 of http://www.publichealth.va.gov/docs/flu/VA_influenza_manual09-10.pdf)
  
  Training and education of healthcare personnel
  
  
• All healthcare personnel should receive training on influenza prevention and risks for complications of influenza. The training should include information on risk assessment; isolation precautions; vaccination protocols; use of engineering and administrative controls and personal protective equipment; protection during high-risk aerosol-generating procedures; signs, symptoms, and complications of influenza; and to promptly seek medical attention for any concerns about symptoms of influenza.
  
  Healthcare Personnel at Higher Risk for Complications of Influenza
  
  
• Vaccination and early treatment with antiviral medications are very important for healthcare personnel at higher risk for influenza complications because they can prevent hospitalizations and deaths. Healthcare personnel at higher risk for complications should check with their healthcare provider if they become ill so that they can receive early treatment.

UPDATE - September 14, 2009

SUBJECT: Clarification regarding length of self-isolation for medical students who are experiencing an influenza-like-illness

In our September 8 memo ("Novel H1N1 influenza preparations for medical schools and students"), we noted that "Students, faculty, and staff with flu-like illness should self-isolate at home or at a friend/family member's home until at least 24 hours after they are free of fever, or signs of a fever, without the use of fever-reducing medicines." Please note that this guidance applies to students, faculty and staff who do not have patient care responsibilities.

The infection control guidance that is referenced for health care profession students later in the memo ("Remind health-care profession students to follow infection control guidance for health-care workers.") is a May 13 document that is still in effect. Students, faculty, and staff who have clinical responsibilities in communities where novel H1N1 transmission is occurring (or who have been working in areas of the hospital where H1N1 patients are present) and who develop a febrile respiratory illness, should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.

The CDC is continuing to update their guidance documents from this spring. We are in direct contact with the CDC and we will alert you as soon as we learn of any changes to the infection control or other guidance documents that are relevant to medical schools.

We would like to thank Michael Muszynski, MD, (Regional Campus Dean at Florida State University College of Medicine's Orlando Campus) for bringing this important clarification to our attention.

SUBJECT: Novel H1N1 influenza preparations for medical schools and students

DATE: September 8, 2009

TO: Student Affairs Deans and the Group on Student Affairs

FROM: Henry Sondheimer, M.D., Senior Director, Student Affairs and Student Programs AAMC
Rika Maeshiro, M.D., M.P.H., Director, Public Health and Prevention Programs AAMC

The Centers for Disease Control and Prevention (CDC) has released a series of guidance materials to prepare and plan for the novel H1N1 influenza virus, including recommendations aimed at institutions for higher education. Here at the AAMC we are monitoring this closely and the enclosed is a first update for this academic year which we hope will be helpful to you. Because the H1N1 virus is causing a greater disease burden in people younger than 25 years of age, and because medical students work in clinical environments, medical schools may wish to consider the following background information and questions as they plan for the influenza season.

Background

• In the United States, significant novel H1N1 illness continued into the summer, with localized and in some cases intense outbreaks. Most people who have become ill have recovered without requiring medical treatment. Although the severity of flu outbreaks during the fall and winter of 2009-10 is unpredictable, more communities may be affected than in spring/summer 2009, reflecting wider transmission and possibly greater impact.
  

• CDC guidance includes: 1) recommendations to use now, during this academic year, assuming a similar severity to the spring/summer H1N1 flu outbreak, and 2) recommendations to consider adding if the flu begins to cause more severe disease. Recommendations to consider immediately include:



• Promote self-isolation at home by non-resident students, faculty, and staff: Students, faculty, and staff with flu-like illness should self-isolate at home or at a friend/family member's home until at least 24 hours after they are free of fever, or signs of a fever, without the use of fever-reducing medicines. Do not require a doctor's note for students, faculty, or staff to validate their illness or to return to work, as medical facilities may be extremely busy and may not be able to provide such documentation in a timely way.

• Considerations for high-risk students and staff: People who become ill with flu-like illness and are at high risk for flu complications should speak with their health care provider as soon as possible. Early treatment with antiviral medications often can prevent hospitalizations and deaths. Typical groups on medical school campuses who are at higher risk of complications from flu if they get sick include: People age 65 or older; pregnant women; adults and children who have asthma; other chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders such as diabetes; and adults and children with immunosuppression. People age 65 and older appear to be at lower risk of 2009 H1N1 infection compared to younger people, but if older adults do get sick from flu, they are at increased risk of having a severe illness.

• Discourage campus visits by ill persons: Use communication methods such as e-mail, posters, flyers, and media coverage to discourage people with flu-like illness from attending medical school events.

• Encourage hand hygiene and respiratory etiquette of both people who are well and those that have any symptoms of flu.

• Routine cleaning: Establish regular schedules for frequent cleaning of high-touch surfaces (for example, bathrooms, doorknobs, elevator buttons, and tables). Provide disposable wipes so that commonly used surfaces (for example, doorknobs, keyboards, remote controls, desks) can be wiped down by students before each use.

• Remind health-care profession students to follow infection control guidance for health-care workers.

• The vaccine for the novel H1N1 influenza is anticipated in mid-October. The immediate target groups to receive vaccination include:


• Pregnant women
  
• People who live with or care for children younger than 6 months of age
  
• Healthcare and emergency medical services personnel
  
• Persons between the ages of 6 months and 24 years old
  
• People ages of 25 through 64 years of age who are at higher risk for 2009 H1N1 because of chronic health disorders or compromised immune systems.

Questions to Consider

• Does your school support a culture in which ill students, faculty, and staff are supported in their decision to stay home while ill?
  
  • Do sick leave policies facilitate faculty and staff staying home when they are ill or caring for an ill family member?
    
  • Do students policies regarding missed classes/examinations and late assignments prevent them from staying home when ill or
  • prompt them to return to class or take examinations while still symptomatic and potentially infectious?
    
  • Are distance learning or web-based educational opportunities available that can help students maintain self-isolation?
    
• Can your medical school maintain communications with students who are ill and staying home? Should your school consider a "flu buddy" system that facilitates a student network to support one another in case of illness?
  
• Is your medical school aware of the medical students, faculty, and staff who may be at higher risk of complications from the novel H1N1 influenza virus because of chronic medical conditions or pregnancy?
  
• Does your medical school regularly provide seasonal influenza vaccination for medical school students, faculty, and staff? Will the medical school facilitate the administration of the novel H1N1 vaccine to medical students when the vaccine is available?
  
• Does your medical school facilitate resiliency by encouraging students to maintain a "prepared" household, in case they must stay at home for several days? Or in case they experience other emergencies?
  
• Should your medical school encourage good hand hygiene and respiratory etiquette through posters, flyers, and other methods?
  
• Is the medical school in contact with local public health agencies in order to stay apprised of local conditions?
  
• How will the medical school communicate with students, faculty, and staff if a severe outbreak occurs locally?
  
• Has a decision-making process been identified to consider additional steps if the flu begins to cause more severe disease?

Resources

CDC Guidance for Responses to Influenza for Institutions of Higher Education during the 2009–2010 Academic Year

Preparing for the Flu: A Communication Toolkit for Institutions of Higher Education
Frequently asked questions, posters, and templates for communications to students, faculty, staff, and parents.

Contacts

The AAMC will continue to follow the H1N1 situation and will provide updates as needed. Please contact either Henry Sondheimer, M.D., at hsondheimer@aamc.org or Rika Maeshiro, M.D., M.P.H., at rmaeshiro@aamc.org if you have any questions or suggestions on how we may be of assistance to you during this influenza season.