Practical Measures to Reduce Swine Flu Transmission: An Expert Interview With Georges C. Benjamin, MD, FACP, FACEP (E)

Laurie Barclay, MD

April 30, 2009

April 30, 2009 — Editor's note: Now that the World Health Organization has raised the pandemic alert level for swine influenza A (H1N1) to phase 5, healthcare professionals must be prepared to respond effectively with case diagnosis, management, and minimizing transmission to help contain this outbreak. The US Centers for Disease Control (CDC) have issued guidance for clinicians, state public health laboratories, and public health and animal health officials.

In particular, clinicians should consider the possibility of swine influenza virus infections in patients presenting with febrile respiratory illness, collect a respiratory swab for swine influenza testing, and contact the state or local health department to facilitate timely diagnosis. To learn more about practical advice clinicians should give their patients regarding how to minimize their chances of contracting swine influenza or spreading it to others, Medscape Infectious Diseases interviewed Georges C. Benjamin, MD, FACP, FACEP (E), executive director of the American Public Health Association.

Medscape: Once swine flu has been suspected or confirmed in a particular community, what are the most important recommendations for home isolation and household contacts, and how should patients and caregivers be counseled regarding these recommendations?

Dr. Benjamin: In a situation as rapidly changing as this one, the best thing clinicians can do is follow the advice of the local, state, and federal health officials. As we know more about the virus, recommendations will likely change and the most current recommendations are what should be passed on to patients.

In the meantime, healthcare professionals can pass on the same general guidance that is used with seasonal influenza outbreaks. They should let patients know that once the virus is in a community, people should follow basic precautions to prevent the spread of any respiratory disease. This means protecting yourself by distancing yourself from people who are coughing or sneezing; washing your hands frequently; and keeping your hands away from your eyes, nose, and mouth. It also means using good judgment in keeping your environment clean, such as doorknobs.

Health providers should let caregivers know that if someone in the household is sick, they should limit exposure to them by keeping them in a room separate from common areas, such as a spare bedroom, and limit the number of people who enter the room. Caregivers should also be given guidance on using gowns, masks, or gloves when handling infectious material. The protective barriers serve as extra layer of protection and can be used if an individual will be handling soiled tissues or other contaminated objects.

Patients should also be advised that if they have kids and they're sick, they should keep them home from school. And also that if they don't feel well, stay home from work or other group activities. Patients should consult their healthcare provider about the illness and protections for the caregiver. More specific information for caregivers can be found at

Medscape: Are there any specific guidelines or recommendations for school nurses, in terms of management of students with symptoms suggesting swine flu and in terms of isolation, school closings, or other precautions?

Dr. Benjamin: This is an evolving situation, so I recommend that people keep up with the guidelines. CDC has posted guidance on how schools and administrators should best manage this situation to protect the health of students, teachers, and workers. Follow this at

School nurses are a frontline resource and they should follow CDC clinical guidelines on identifying potential H1N1 flu cases. According to CDC, health providers should contact their state public health department to report suspected cases of swine-origin influenza A (H1N1) virus infection and to obtain information on what clinical and epidemiologic data to collect and specimen shipment protocols in their state.

Medscape: How effective are disposable face masks vs respirator masks worn by healthcare professionals, and what are the indications for appropriate use of each?

Dr. Benjamin: It's not clear just how effective face masks are in preventing transmission of the H1N1 virus. In areas with confirmed cases of the virus, a combination of actions will prove most effective in preventing further spread, including hand washing and limiting exposure to people who are ill, coughing, or sneezing.

In crowded settings or when close contact with people who may be sick cannot be avoided, a face mask may serve as a useful physical barrier, but one should understand that the simple surgical mask is not nearly as protective as the N-95 respirator mask. The N-95 respirator must be fitted and worn properly to be most effective. New guidance on the use of face masks may emerge as we learn more about this virus.

Currently CDC recommends that when crowded settings or close contact with others cannot be avoided, the use of face masks or respirators in areas where transmission of swine influenza A (H1N1) virus has been confirmed should be considered as follows:


  1. Whenever possible, rather than relying on the use of face masks or respirators, close contact with people who might be ill and being in crowded settings should be avoided.

  2. Face masks should be considered for use by individuals who enter crowded settings, both to protect their nose and mouth from other people's coughs and to reduce the wearers' likelihood of coughing on others; the time spent in crowded settings should be as short as possible.

  3. Respirators should be considered for use by individuals for whom close contact with an infectious person is unavoidable. This can include selected individuals who must care for a sick person (eg, family member with a respiratory infection) at home.


More information is available at

Medscape: Are there any recommendations for precautions that could be taken by businesses, public establishments, schools, churches, etc, to minimize the likelihood of spread in these areas, both before and in the event of confirmed cases in the community?

Dr. Benjamin: There are many different lists prepared during the last several years to help people be better prepared for an emerging infectious disease or other health threat. You can find some of these lists at, and In terms of precautions to minimize the spread of disease, using good judgment may be the first step. For example, if you're not feeling well, stay at home and avoid crowds or close contact with others. Many activities such as shopping, taking classes, or even participating in religious services can be done online via the Internet, minimizing contact with others.

Encouraging home isolation of cases is strongly recommended by CDC. The current recommendation for schools is that dismissal of students should be strongly considered in schools with a confirmed or a suspected case epidemiologically linked to a confirmed case.

More information is available here:

Medscape: Is there any evidence favoring alcohol-based hand sanitizers vs hand washing; covering a cough or sneeze with the arm or shoulder vs hand; and/or other personal hygiene measures individuals should follow?

Dr. Benjamin: People should wash their hands as frequently as possible, especially if they are visibly soiled, for at least 20 seconds. Warm water and soap will emulsify the dirt and grease, and the mechanical action of rubbing your hands together helps to eliminate the dirt and germs. Use of alcohol-based sanitizers is a good second choice when you don't have access to soap and water. Some people may not be able to use alcohol due to skin sensitivities or other conditions. You should also cough or sneeze into your elbow or arm to reduce the spread of germs to your hands.

Medscape: Should disinfectants or antibacterial cleansers be used on surfaces, and how often?

Dr. Benjamin: Using common sense is often the best approach. If someone in a home is sick, people will want to take extra precautions to keep others in the house from getting sick. They should throw away in the trash tissues and other disposable items used by the sick person.

Surfaces (especially bedside tables, surfaces in the bathroom and toys for children) should be kept clean by wiping them down with a household disinfectant according to directions on the product label. Thoroughly wash linens, eating utensils, and dishes belonging to those who are sick before reusing. And people shouldn't forget to wash their hands when done cleaning.

Medscape: In addition to avoiding unnecessary travel to Mexico, how should clinicians advise their patients regarding travel to Canada or to states with confirmed cases, airline travel in general, and attendance at sports events, concerts, or other large public gatherings?

Dr. Benjamin: Health providers should advise their patients to make prudent decisions about what their relative risk is and determine the best course of action. Clinicians should also take into account each patient's health status. For example, if you have a patient with a chronic illness or who is immunocompromised, it probably makes good sense to recommend that they take extra care and avoid activities or places such as a public gathering, concerts, or sports activities where risk of exposure is greater.

You should also follow the advice and guidance of your local, state, and federal public health officials. Regarding travel to Mexico, CDC offers specific guidance at

Medscape: What do you regard as the greatest challenges and priorities regarding containment of this outbreak?

Dr. Benjamin: For clinicians, a primary challenge with this outbreak is communicating adequately with patients without scaring them or inciting panic. Additionally, another challenge is staying on top of all the information. The information for clinicians is constantly changing, as are the recommendations we should pass on to patients.

For scientists, determining the best course of action with regard to vaccine development is a challenge. If this becomes a lethal pandemic, we'll obviously need to ramp up all efforts, which will present challenges for our resources and economy.

All CDC guidance documents are available at:


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