"Enquiring" minds want to know: Understanding swine flu in the dental setting

By Noel Kelsch, RDHAP

My mother called me last month and asked if I had a case of masks to spare. She then went on to tell me I should stop going out for Mexican food and should throw away any pork I might have. Mind you, my mother is a very intelligent woman, but she reads interesting magazines and depends on those around her to make decisions. She heard from a friend whose son-in-law works at a hospital (as a guard — a true authority) that eating Mexican food or pork causes the spread of swine flu. She gathered information from another reliable source (a friend whose sister is friends with a minister who heard about the cousin of a parishioner with the disease) that the entire family should wear masks, even to bed. My mother also found a vital article in the National Enquirer that dispelled all the myths and told her she better get her will in order since we have only weeks to live. I am always amazed when my very educated mother falls for the "we have it on authority" pitch. Frequently she is ready to move, change her medication, or wear a mask to bed in the name of survival because of what one of those sources says.

The swine flu has caused myths to abound. So where do we go for answers on the spread, treatment, and prevention of this disease? The Centers for Disease Control and Prevention (CDC) is a reliable source. This agency of the U.S. Department of Health and Human Services works to protect public health and safety by providing information to enhance health decisions, and it promotes health through partnerships with state health departments and other organizations. The CDC focuses national attention on developing and applying disease prevention and control (especially infectious diseases), environmental health, occupational safety and health, health promotion, prevention, and education activities designed to improve the health of the United States.

The CDC has had an influx of inquiries regarding this disease, and has devoted an entire section of their Web site to it. Let's separate fact from fiction.

What is "swine flu"? The scientific name is novel influenza A or H1N1. It is a new influenza virus first detected in the U.S. in April 2009. Other countries, including Mexico and Canada, have reported cases of this virus. Swine flu is spread from person to person in the same way as the regular seasonal flu is spread — through the sneezing and coughing of people infected with it. It's called the swine flu because it has genes very similar to the flu virus that normally occurs in pigs in North America. Once this virus was studied it was learned that it is very different than the one pigs acquire. At this point, there are no statistics on the severity of this disease in terms of illness and death compared with other influenza viruses. Because it is new people do not have immunity to it, and as a result, the illness may be more severe and widespread. There is no vaccine to protect against this virus, thus there may be more hospitalizations and fatalities associated with it.

What's a health-care provider to do? The CDC has issued guidelines for health-care professionals that can be obtained by going to www.cdc.gov/swineflu/, and clicking on Guidance for Professional. This information is updated regularly and may change daily. Check frequently with the CDC swine flu Web sites for the latest information. Dental health-care professionals are encouraged to view the Web page for the latest updates.

Here is the most current information:

"Prevention of Disease Transmission in the Dental Healthcare Setting. Patients with an acute respiratory illness may present for dental treatment at outpatient dental settings. The primary infection control goal is to prevent transmission of disease. Early detection of a suspected or confirmed case of swine influenza and prompt isolation from susceptible persons will reduce the risk of transmission. To prevent the transmission of respiratory infections in health care settings, including influenza, respiratory hygiene/cough etiquette infection control measures should be implemented at the first point of contact with a potentially infected person."

Infection control issues during patient assessment:

• Patients with an acute respiratory illness should be identified at check-in and be placed in a single-patient room with the door closed.

• Offer a disposable surgical mask to persons who are coughing or provide tissues and no-touch receptacles for used tissue disposal.

• The ill person should wear a surgical mask when outside of the patient room.

• Dental health care personnel assessing a patient with influenza-like illness should wear a disposable surgical facemask*, non-sterile gloves, gown, and eye protection (e.g., goggles) to prevent direct skin and conjunctival exposure. These recommendations may change as additional information becomes available, so check the CDC Web site for updates at www.cdc.gov/swineflu/guidelines.

• Patient and dental health-care workers should perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) after contact with respiratory secretions and contaminated objects/materials.

• Routine cleaning and disinfection strategies used during influenza season can be applied to the environmental management of swine flu. Find more information at www.cdc.gov/ncidod.

* Until additional, specific information is available regarding the behavior of this swine influenza A (H1N1), the guidance in the October 2006 "Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic" (www.pandemicflu.gov/plan/healthcare) is being recommended at this time. These interim recommendations will be updated as additional information becomes available.

Frequently Asked Questions

1) What do I do if a patient presents for routine treatment and has acute respiratory symptoms with or without fever? If the dental health-care professional suspects the illness could be due to swine flu (symptoms include fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea), elective dental treatment should be deferred and the patient should be advised to contact his or her general health-care provider. The general health care provider will determine whether influenza testing or treatment is needed. Refer to www.cdc.gov/swineflu/guidelines for case definition and other information.

2) What do I do if a patient with acute respiratory symptoms requires urgent dental care? If urgent dental care is required and swine flu has either been confirmed or suspected, the care should be provided in a facility (e.g., hospital with dental care capabilities) that provides airborne infection isolation (i.e., airborne infection isolation room with negative pressure air handling with six to 12 air changes per hour).

For aerosol-generating procedures, use a procedure room with negative pressure air handling. Personnel providing direct patient care for suspected or confirmed swine influenza A (H1N1) cases should wear a fit-tested disposable N95 respirator when entering the patient room and performing dental procedures. Respirator use should be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA) regulations. Information on respiratory protection programs and fit test procedures can be accessed at www.osha.gov.

3) What do I do if staff members report to work with acute respiratory symptoms?

• Staff experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work.

• Staff experiencing ILI that wish to seek medical care should contact their health-care providers to report illness (by telephone or other remote means) before seeking care at a clinic, physician's office, or hospital.

• Staff who were not using appropriate personal protective equipment during close contact with a confirmed, probable, or suspected case of swine flu A (H1N1) during the case's infectious period should receive chemoprophylaxis according to CDC guidance www.cdc.gov/swineflu/recommendations.

• Staff members who have difficulty breathing or shortness of breath, or are believed to be severely ill, should seek immediate medical attention.

I may never get my mother to stop reading the National Enquirer or listening to "authorities," but by following these guidelines we can help prevent the spread of this disease. Respiratory hygiene/cough etiquette infection control measures along with contact precautions are currently recommended for preventing transmission of swine flu in the dental health-care setting. The CDC is working very closely with officials in states where human cases of swine flu A (H1N1) have been identified, as well as with health officials in Mexico, Canada, and the World Health Organization. This is a rapidly evolving situation and CDC will provide updated guidance and new information as it becomes available. Send your patients and coworkers to www.cdc.gov/h1n1flu so they can receive information from a reliable source.

Noel Brandon Kelsch, RDH, writes the Infection Control column for RDH magazine. She is a freelance cartoonist, writer, and speaker. She has received many national awards including Colgate Bright Smiles Bright Futures and Sunstar/RDH Award of Distinction. Her family lives in Moorpark, Calif. She can be contacted at [email protected]