Earlier this week, the World Health Organization raised the Pandemic Alert Level to Phase 4, sending the world's media and medical communities into a frenzy of worry and action. Phase 4 alerts are issued whenever human to human transmission is confirmed for an animal or human-animal influenza or virus, and the transmission is suspected of being capable of causing "community level outbreaks." With 100 confirmed U.S. cases - including 1 death - in several states and communities (as of the writing of this article) the implications for EMS providers cannot be overlooked.

Editor's Note: Since the writing of this article on April 29, the WHO has raised the worldwide pandemic alert level to Phase 5, indicating a "strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short." The CDC reported a total of 109 confirmed cases and one death as of April 30. For updates visit cdc.gov/swineflu.

In addition, this "Swine Flu" is not the same Swine Flu that has broken out several times in the past, although the viruses are being compared in the media. This new virus, which also incorporates human and avian virus elements, is now officially and more appropriately known as influenza A (H1N1).

Symptoms of an H1N1 infection are identical to that of influenza. The symptoms include lethargy, high fever (greater than 102°F), weakness, sore throat, runny nose, coughing, loss of appetite, nausea, and vomiting. In severe cases, patients can develop shortness of breath progressing to respiratory distress, dehydration, cyanosis, mental status changes, and severe anxiety and agitation.

Influenza A (H1N1), like other influenza viruses, is airborne and can be spread through direct contact as well. Close proximity with infected swine or individuals can cause transmission. Typically human-to-human transmissions occur when an infected individual coughs or sneezes, or when an infected individual touches something (rails of a cot) with the virus and then another individual touches the same surface before it is cleaned. Airborne transmission often occurs when individuals are within "close contact," which O.S.H.A. defines as 6 feet, but the World Health Organization defines as 1 meter - just over 3 feet. Once infected, the incubation period is as short as 24 hours, or up to a week depending on the source.

As fear over influenza A (H1N1) sweeps through the country, there may be a surge in 911 calls for high fever, shortness of breath, and weakness. EMS is the front line of the health care system, and it is critical that we do our part to help prevent inadvertent virus spread.

Be alert, but not paranoid. Maintain a high index of suspicion any time an ambulance is requested for fever or any flu like signs and symptoms. While evaluating patients, ask about recent travel as a part of their medical history. Suspect a potential influenza A (H1N1) infection any time a patient has flu-like symptoms and they, or someone close to them, has traveled to an area with a confirmed virus outbreak. Currently, there is an outbreak in Mexico, and many cases have been diagnosed in New York City. Cases have also been confirmed in California, Kansas, Ohio, Texas, Canada, New Zealand, Israel, Spain and the United Kingdom. (See updates at cdc.gov/swineflu).

Most patients with intact immune systems will fully recover from the virus. Pediatric patients with immature immune systems, individuals on immunosuppressant drugs, and elderly patients with weakened immune systems are at an increased risk for developing more serious symptoms, just as they are with other influenza viruses. Additionally, people living in close quarters such as college dorms, jails, skilled nursing facilities, and homeless shelters risk having multiple people become exposed during the virus's incubation period.

Remember, the incubation period is 24 hours to 7 days, which means that someone who traveled to an area with confirmed cases a month ago is unlikely to have an influenza A (H1N1) infection. While a patient with a history of travel to an area with confirmed cases and flu-like symptoms may raise suspicion, proper diagnosis can only be done with lab testing.

Routine airborne isolation precautions are beneficial in helping prevent influenza A (H1N1) transmission. Any time you are in close contact, or within 6 feet, of a symptomatic patient, wear gloves and a face mask. While the benefit of face masks in combating influenza strains is, at best, debatable, an alternative option for the coughing patient is to place a face mask on them - providing they are not in respiratory distress. A non-rebreather mask will not prevent transmission.

There are several things that EMS providers can do to help control the influenza A (H1N1) virus spread:

• Wash hands with soap and warm water for at least 30 seconds following every patient contact
• Provide patients with tissue paper to sneeze and cough into
• Maintain a safe, yet professional, distance from the patient; do not make them feel isolated
• Clean the stretcher frame and mattress with approved virus-killing cleaning supplies provided at hospitals or by your own service
• Clean the inside surfaces of the ambulance with approved virus-killing cleaning supplies following any high-risk patient contact
• Turn the ambulance exhaust fan on to promote air flow through the patient compartment

Good communication is important if you truly suspect a patient may have the virus. However, stating this information over the radio could cause unnecessary anxiety from other EMS providers and laypersons listening to radio traffic. Consider contacting an emergency department receiving potential patients via cell phone to relay findings, or simply advise the ED that the patient requires isolation precautions.

EMS management of influenza A (H1N1) is symptom-based. Treat suspected dehydration with IV fluids and shortness of breath as needed. Protect the critical systems. After a physician evaluation, patients can be treated with anti-viral drugs. Antibiotics are ineffective as are previous influenza and H1N1 inoculations.

We are learning more about the influenza A (H1N1) virus each hour, and every day more cases are being discovered. The CDC and WHO have already said many cases may not be diagnosed simply because the tests will not be performed. It is important for us in EMS to help control it, and help individuals to not panic about the virus. Keep a mindful eye for sudden groups of people with similar flu-like symptoms, and take thorough patient histories. For more information, visit the websites for the Center for Disease Control and the World Health Organization.

Kevin Thomas Collopy, BA, CCEMT-P, NREMT-P, WEMT is a flight paramedic for Spirit Medical Transportation Service in central Wisconsin. He is the author of numerous magazine articles, textbook chapters, and flash based CE lessons. He is an adjunct EMS faculty member for Mid-State Technical College, a consultant with Emergency Preparedness Systems, LLC, and a Lead Instructor for Wilderness Medical Associates. You can reach Kevin at kcollopy@colgatealumni.org.

Related:

• Swine Flu: Keeping Perspective
• Podcast: Swine Flu Advisory for EMS
• Swine Flu Scare has EMS Officials Scrambling
• U.S. Responding as if Swine Flu Will Be Pandemic
• cdc.gov/swineflu
• Who: Information on swine influenza
• International SOS Swine Flu ("Pig Flu") Update
• International Association of EMS Chiefs: Influenza Guidance Updates
• Press Briefing on Swine Influenza with Department of Homeland Security, Centers for Disease Control and Prevention, and White House

Additional Resources:

• EMS Magazine April 2009 article: Surge Capacity: Is your system prepared for the victims of a large-scale incident?
• Should We Fear the Pandemic?
• The Coming Pandemic
• Pandemic Flu: Critical Infrastructure Management
• Pandemic -- Are We Prepared?

Pandemic News Archives:

• Pandemic Readiness: How Prepared are Facilities Really?
• White House Releases Fact Sheet on Implementation of National Strategy for Pandemic Influenza
• Report: Pandemic Plans Address Vaccines but Not Ethics
• Officials Examine Pandemic Precautions for First Responders