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General Information on H1N1 Influenza
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Northwestern University Health Service - Evanston > General Information on H1N1 Influenza
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Introduction
The worldwide publicity surrounding the H1N1 influenza pandemic has caused anxiety among the general population and the Northwestern Community and many have asked how the University plans to respond to this infectious threat. Such concerns have been exacerbated by information from a variety of reputable and less reputable sources that is frequently updated, often conflicting, and, at times, simply incorrect. Nonetheless, it is important to keep the current H1N1 pandemic in perspective.
Safeguarding the environment and protecting the public health should be a shared responsibility among Northwestern faculty, staff, and students; all may need to make temporary accommodations to respond effectively to this unusual situation. After all, it is in the interest of the entire Northwestern community to do so, as everyone has not only an occupational or academic but also a personal health stake in the outcome. We are all in this together, and we need to take care of one other.
Below are some of the key facts and considerations that inform the University’s decision-making process in response to the evolving pandemic. It is important to remember, however, that this is an evolving situation and that recommendations will likely change as additional information become available.
Why is H1N1 Influenza different from regular (seasonal) flu?
Every year the United States (as well as the rest of the world) experiences seasonal flu epidemics; and, indeed, it is for this reason that flu shots are offered in late fall in the northern hemisphere. Moreover, contrary to what many believe, seasonal influenza is not necessarily a benign illness; 350,000-500,000 people worldwide and 36,000 people in the United States die each year of influenza. Typically, however, seasonal influenza deaths occur in the very young, the elderly, and those with chronic medical illnesses.
At least at the present time, the current H1N1 influenza pandemic appears to have a mortality rate similar to that of seasonal influenza, so why the great concern among public health authorities? There are multiple reasons. First, the H1N1 virus has spread faster than any known previous influenza outbreak, and it is now worldwide (i.e., an official “pandemic”) and persistent, even at times of the year when seasonal influenza typically disappears. Second, the vast majority of the world’s population has no immunity to this virus. Third, the H1N1 influenza virus has significant biological differences from typical seasonal influenza viruses, and there is legitimate concern that it could evolve to become more deadly. Fourth, consistent with previous deadly pandemics and in contrast to seasonal influenza, healthy young adults are overrepresented among H1N1 influenza deaths, the population that constitutes the vast majority of Northwestern students. It is possible that H1N1 pandemic concerns may, in retrospect, mirror the Y2K fears, many of which turned out to be unfounded. But this can only be known in retrospect, and the University is committed to implementing H1N1 policies and procedures based on public health authority information and guidelines.
Virus Transformation
Influenza viruses are well known for their ability to change over time. Through recombination with other viruses, mutations, and other mechanisms, they constantly evolve so as to elude host defenses. Thus, while the Influenza A H1N1 virus appears mild-moderate in severity at this time, it could change and become more dangerous. Indeed, previous influenza pandemics have typically occurred in 2-3 month waves, often with the initial wave presenting with mild symptoms only to become more dangerous and lethal in subsequent waves. No one can predict whether or how this Influenza A H1N1 virus may change over time, so, as the WHO and CDC have repeatedly cautioned, vigilance remains important. Nonetheless, given the mild-moderate nature of the vast majority of the illnesses identified thus far, there is no reason for panic or overreaction at this time.
Public Health Authority Guidelines and Recommendations
As the H1N1 influenza pandemic has evolved, public health authorizes such as the CDC and WHO (World Health Organization) have revised their guidelines and recommendations as well. At times, guideline changes have come with little warning and have incorporated recommendations requiring substantial changes in operating procedures. Northwestern is making its best efforts to comply with CDC and other guidelines in its response to the H1N1 pandemic.
CDC Case Definition for Suspected H1N1 Influenza
The signs and symptoms of H1N1 influenza, like other types of influenza, are non-specific: fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and fatigue. Nonetheless, the CDC has established specific criteria for a suspect case of H1N1 influenza:
- Fever (temperature of 100 degrees F/37.8 degrees C or greater), AND
- Either cough or sore throat
- No other known cause for the symptoms
Examination and Testing for Suspected H1N1 Infection
- Examination for Suspected H1N1 Infection
- Given that the estimated number of H1N1 infections in the United States is over 1,000,000 and that H1N1 cases have been documented on campus, there is no reason to doubt that the virus is present at Northwestern University. In addition, for most individuals the illness is mild and does not require specific medications. Finally, if everyone with fever and either a cough or sore throat were to visit a physician, the American health care system would be rapidly overwhelmed. For these reasons, the CDC recommends that those with H1N1 symptoms not even visit a physician unless they are at “high risk” for complications or develop warning signs of severe infection (see sections below).
- NUHS is establishing online and telephone triage systems through which students with suspected H1N1 infection can determine if they should isolate themselves or if further evaluation is required (e.g., for treatment with antiviral medications). The vast majority of such students will not need to be seen by a physician at the Health Service, and students and parents as well as University faculty and staff should not be surprised to learn, in an individual case, that a student was asked not to come to NUHS. NUHS will not turn down a student’s request to be seen, but it will encourage those with H1N1 symptoms who are not at high risk and who are without warning signs of severe illness to begin isolation and treatment in their residence hall without further evaluation.
- Testing for H1N1 Influenza
- As noted above, the CDC recommends that those with H1N1 symptoms not even visit a physician unless they are at “high risk” for complications or develop warning signs of severe infection. Similarly, the CDC no longer recommends routine testing for H1N1 influenza as the illness is widespread throughout the world (thus, a “pandemic”), and there are estimated to be over 1,000,000 cases in the United State alone. While some students may elect to be tested for H1N1, it is important to understand that the vast majority of students cannot be expected to provide documented proof of H1N1 infection. New testing developments and changes in guidelines may occur as more becomes known about the H1N1 virus.
What to Bring to School
- Northwestern University strongly advises all students to bring to school the essentials of a “flu kit” such as the following:
- Thermometer
- 10-25 Surgical face masks
- Alcohol –based hand sanitizers (e.g., Purell)
- Tylenol or Motrin for fever
When to Call the Health Service
- All ill students should feel free to call the Health Service with questions and/or to undergo a telephone triage process for determining if they may have a suspect case of H1N1 influenza. Students with suspect H1N1 illness who are at high risk for complications or who have severe symptoms (both defined below) should call as soon as possible.
Academics and Medical Illness Documentation
- The Provost has asked all University faculty to be flexible in dealing with the H1N1 pandemic. In particular,
- Ill students should not be penalized for missing the first day of class or academic assignments, although such assignments (e.g., tests and papers) will need to be made up per agreements with individual professors.
- Documentation of suspected H1N1 illness will not be necessary. Indeed, as already noted, the CDC recommends that unless an individual is at high risk of complications or has severe symptoms (both defined below), he or she should not go to the doctor’s office or, in this case, the University Health Service in order to avoid infecting others and overwhelming available health services.
Isolation
In its August 5, 2009 recommendations for colleges and universities the CDC changed its guidelines for isolation of individuals who meet the criteria for a suspect case of H1N1 influenza. Whereas before the CDC had recommended that such individuals be isolated for 7 days from the onset of symptoms or 24 hours after symptoms resolve, whichever was longer, its new guidelines are as follows:
- People with fever (temperature of 100 degrees F/37.8 degrees C or greater) AND either a cough or sore throat should isolate themselves from others until at least 24 hours after they are free of fever without the use of fever-reducing medications.
Data from this spring indicate that most persons with H1N1 infection had a fever that lasted 2-4 days; thus, under the new CDC guidelines, self-isolation will typically require a 3-5 day period away from others.
The CDC does not believe that all H1N1-infected students need leave the university or go home (although those who can return home for isolation are encouraged to do so); the vast majority can be isolated in their dormitories and residence halls as long as certain precautions are taken. In reviewing the available plans of many universities in the United States, it appears that most do not have sufficient housing to remove ill students from their residence halls; thus, self-isolation in one’s own room appears to be the evolving norm. Note, however, that state and local public health authorities may modify these guidelines if the H1N1 virus becomes more severe or lethal, or if local outbreaks exceed certain parameters.
Nuts and Bolts of Isolation in Residence Halls
What is the reality of self-solation in residence halls? What will this mean for students and their academic pursuits as well as for University staff that will need to attend to such students?
- It appears that there will be few open residence hall rooms this fall. Insofar as such rooms are available, students with suspected H1N1 influenza may be isolated in them. As an alternative, however, the University is seeking additional temporary housing in local hotels and elsewhere for roommates of infected students.
- Whether in isolation or elsewhere, all university faculty, staff, and students need to scrupulously employ respiratory etiquette and personal hygiene techniques that will limit the spread of H1N1 influenza (and, of course, other viral and bacterial diseases). See below for a review of these procedures.
- Leaving One’s Room and Use of Face Masks
- While many medical authorities have recommended the use of surgical face masks to reduce spread of N1N1 influenza, the data is not particularly convincing. For this reason, the CDC believes that university students in isolation should not leave their rooms unless there is a medical necessity to do so. In short, masks are not a substitute for isolation, and students with suspected or proven H1N1 influenza should not attend classes.
Antiviral Medication
- Because the H1N1 virus currently appears to be no more severe, for most persons, than seasonal influenza, the CDC does not recommend routine use of antiviral medications for those exposed to the illness or even those with proven H1N1 infection. However, treatment with antiviral medications may be appropriate for those individuals at increased risk for complications of influenza or those with severe symptoms (see below).
- It is important to understand the reasoning behind these new recommendations. While antiviral medications such as Tamiflu or Relenza may be used for seasonal influenza, the vast majority of seasonal influenza sufferers do not use such medications and, instead, employ conservative measures such as bed rest, fluids, and analgesics for pain. In addition, Tamiflu, the most commonly prescribed antiviral medication for H1N1 treatment or prophylaxis, may be in short supply in many pharmacies and may cause a variety of side effects of which nausea and vomiting are the most common. Moreover, the medication needs to be started within 48-72 hours of symptom onset to be most effective; even so, it does not necessarily reduce complications but typically shortens illness by 24 hours. The protection afforded by such medication is short-lived once the medication is discontinued.
- These issues, however, are perhaps overshadowed by a greater concern: viral resistance. Since Tamilflu-resistant H1N1 infections are now occurring, public health authorities are concerned that unnecessary use of antiviral medication will result in even greater resistance. If so, the medications may be ineffective for patients who truly need them.
- Individuals with H1N1 influenza who begin a course of antiviral medication should consider themselves still contagious, even though they are on an antiviral medication, until at least 7 days after the onset of symptoms.
Vaccination
- Seasonal flu shots
- It is important that individuals obtain a seasonal flu shot as early as possible this fall. While the seasonal flu vaccine will not prevent infection with the H1N1 virus, it will decrease the risk of becoming ill with other influenza viruses. Moreover, since the symptoms of seasonal and H1N1 viruses are similar and formal testing to distinguish the different viruses is generally not recommended, the fewer influenza-like illnesses one has, the less likely one will need isolation. The University Health Service hopes have available seasonal flu shots for students beginning in late September.
- H1N1 vaccination
- Recently the FDA approved the H1N1 vaccines for use, and the CDC has disseminated a priority list for such vaccinations. The groups recommended to receive the H1N1 influenza vaccine include:
- Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;
- Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated.
- Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and they can transmit the virus to vulenrable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;
- All people from 6 months through 24 years of age
- Children from 6 months through 18 years of age because there have been many cases of novel H1N1 influenza in children, and they are in close contact with each other in school and day care settings which increases the likelihood of disease spread, and
- Young adults 19 through 24 years of age because there have been many cases of novel H1N1 influenza in these healthy young adults, they often live, work, and study in close proximity, and they are a frequently mobile population; and,
- Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
- Although previous information suggested that 2 separate shots would be required for maximum protection against H1N1, it now appears that for most people only one injection will be necessary.
- Remember that vaccinations do not provide immediate protection; it generally takes 8-10 days for the development of a sufficient immune response to the H1N1 vaccination. Thus, one should not assume that he or she is fully protected immediately after H1N1 vaccination. Individuals just recently vaccinated against H1N1 influenza who develop symptoms of fever and either cough or sore throat will still need to isolate themselves, as noted above.
- Fall flu shots
- The CDC recommends that seasonal flu shots be obtained as early as possible this fall, preferably in September, so thatH1N1 vaccination can begin in October
- The seasonal flu shot will not protect against H1N1, and H1N1 vaccination will not provide immunity to seasonal influenza.
- Depending on how and when H1N1 vaccine is released by various manufacturers and the U.S. government, the University Health Service plans to offer students such vaccinations at various sites on campus.
Preventing Spread of H1N1: Respiratory Etiquette and Personal Hygiene
Influenza viruses, including the H1N1 virus, are spread among humans primary by respiratory droplets from coughing or sneezing. These droplets may be deposited directly on the mouth or nose of nearby people, or they be spread when a person touches such droplets on another person or an object (e.g., a telephone, computer keyboard, door knob, or desk) and then touches his or her own mouth or nose. Thus, the key elements of spread prevention are covering coughs and sneezes as well as hand washing.
Perhaps the single most effective intervention to prevent spread of H1N1 influenza is proper respiratory etiquette and personal hygiene (especially hand washing).
- If you are sick
- Stay home and avoid close contact (e.g., within 6 feet) with others as much as possible.
- Avoid travel and do not go to school or work, even with a mask, unless it is absolutely necessary.
- Cover your coughs and sneezes with a tissue, then put the used tissue in a waste basket and clean your hands (after each cough or sneeze).
- Wear a face mask when around others.
- Clean your hands with soap and water or, if soap and water are not available, an alcohol-based hand sanitizer
- Wash your hands often and especially after using tissues or after coughing, sneezing into your hands, or blowing your nose.
- Use soap and warm water when washing your hands and do so for 15-20 seconds (e.g., sing “Happy Birthday” twice at a normal speed).
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- If you are not sick
- Avoid close contact with someone who is ill.
- Clean your hands with soap and water or an alcohol-based hand sanitizer when you come into contact with surfaces (e.g., a telephone, computer keyboard, door knob, or desk) that may be contaminated with virus.
- Avoid touching your mouth, nose, or eyes. Viruses are often spread when a person touches something that is contaminated with virus and then touches his or her mouth, nose, or eyes.
- Avoid shaking hands and always wash your hands after physical contact with others.
- Keep frequently touched common surfaces (e.g., telephones, computer keyboards, door knobs) clean.
- In general, practice good health habits:
- Get plenty of sleep
- Be physically active
- Drink plenty of fluids
- Eat nutritious food
Individuals at Risk for Complications from H1N1 Infection (from CDC)
- Age groups
- Children younger than 5 years old
- Adults 65 years of age and older
- Persons with the following conditions:
- Chronic illness of the lungs (e.g. asthma or cystic fibrosis), heart, kidneys, liver, blood (including sickle cell disease), endocrine/glandular system (e.g., diabetes or thyroid disease), nervous system/brain/spinal cord, or neuromuscular system (e.g. muscular dystrophy or multiple sclerosis)
- Suppressed immune system (e.g., from medications or HIV disease)
- Pregnancy
- Residents of nursing homes and other chronic-care facilities
- Children or adolescents (less than 18 years) on long-term aspirin therapy
High-risk students should contact the Health Service about concerns regarding H1N1 influenza, including whether testing and treatment with antiviral medications are warranted.
Warning Signs of Severe H1N1 Infection (from CDC and WHO)
- Adults
- Difficulty in breathing or shortness of breath, either during physical activity or while resting
- Turning blue (e.g. lips or fingers)
- Bloody or colored sputum
- Pain or pressure in the chest or abdomen
- Dehydration (e.g. sudden dizziness, dizziness when standing, or absence of urination)
- Low blood pressure
- Severe or persistent vomiting
- Seizures (convulsions)
- Altered mental status (e.g., excessive drowsiness, confusion, coma)
- High fever that persists beyond 3 days
- Flu-like symptoms improve but then return with fever and worse cough
- Children
- Fast breathing or trouble breathing
- Bluish or gray skin color
- Not drinking enough fluids
- Severe or persistent vomiting
- Lack of alertness
- Difficulty waking up or not interacting
- Little or no desire to play
- Being so irritable that the child does not want to be held
- Flu-like symptoms improve but then return with fever and worse cough
Summary of Self-Care Steps for Those with H1N1 Influenza Who Are Not at High Risk for Complications and Do Not have Severe Symptoms
- Isolate yourself and protect others from infection.
- According to the CDC, people with fever (temperature of 100o F/37.8oC or greater) AND either a cough or sore throat should isolate themselves from others until at least 24 hours after they are free of fever without the use of fever-reducing medications.
- Most persons with H1N1 infection have a fever that lasts 2-4 days; thus, self-isolation will typically require a 3-5 day period away from others.
- It appears that there will be few open residence hall rooms this fall. Insofar as such rooms are available, students with suspected H1N1 influenza may be isolated in them. As an alternative, however, the University is seeking additional temporary housing in local hotels and elsewhere for roommates of infected students
- Stay home and avoid close contact (e.g., within 6 feet) with others as much as possible.
- Wear a face mask when around other people.
- Avoid travel and do not go to school or work, even with a mask, unless it is absolutely necessary.
- Masks are not a substitute for isolation, and students with suspected or proven H1N1 influenza should not attend classes.
- Cover your coughs and sneezes with a tissue, then put the used tissue in a waste basket and clean your hands (after each cough or sneeze).
- Clean your hands with soap and water or, if soap and water are not available, an alcohol-based hand sanitizer
- Wash your hands often and especially after using tissues or after coughing, sneezing into your hands, or blowing your nose.
- Use soap and warm water when washing your hands and do so for 15-20 seconds (e.g., sing “Happy Birthday” twice at a normal speed).
- Treat yourself for influenza
- Get plenty of rest
- Drink plenty of fluids
- Use Tylenol or Motrin for fever or headache
- Use throat lozenges or salt-water gargle for sore throat
- Use cough medication judiciously
- If your condition worsens or new symptoms develop, please go to the Patient Triage Protocol or contact the Health Service (847-491-8100 Press 0). If any of the following symptoms develop and your condition appears life-threatening, you should call “911” or go to the nearest Emergency Room immediately; otherwise, you should immediately call the Health Service (847-491-8100 Press 0) for an urgent appointment.
- Difficulty in breathing or shortness of breath, either during physical activity or while resting
- Turning blue
- Bloody or colored sputum
- Pain or pressure in the chest or abdomen
- Sudden dizziness
- Severe or persistent vomiting
- Altered mental status (e.g., excessive drowsiness, confusion, coma)
- High fever that persists beyond 3 days
- Low blood pressure
- Flu-like symptoms improve but then return with fever and worse cough
CDC Weblinks
Appropriate Concern and Vigilance
The H1N1 influenza situation remains in evolution. Current thinking and guidelines may change as more information becomes available or the virus changes its character. The University will continue to attempt to follow CDC guidelines and closely monitor changes in WHO, CDC, and local public health authority recommendations, but it is important to remember that tomorrow’s responses may be different than today’s as the situation evolves. Nonetheless, Northwestern will continue to provide sound information, advice, and diagnostic or treatment decisions related to H1N1 influenza.
September 28, 2009
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