for at least 31 pandemics in history. The most lethal “Spanish flu” pandemic of 1918‐1919 is estimated to have caused 50 million deaths globally with 700,000 of those deaths occurring in the United States in a single year. In this pandemic, deaths occurred mainly in healthy 20‐ 40‐year‐olds, which differs from the usual pattern of mortality and morbidity in young children and the elderly during seasonal outbreaks of influenza.
Table 23.1 Suggested Personal Protective Equipment Based on Procedure or Intervention
| Intervention | Gloves | Facial and Eye Protectiona | Gowns |
|---|---|---|---|
| Drawing blood or starting an IV/IO line | Yes | No | No |
| Controlling minor bleeding with pressure or dressing minor skin wound | Yes | No | No |
| Contact with patient with cough or vomiting | Yes | Yes | Yes (if febrile respiratory illness or vomiting) |
| Needle thoracostomy | Yes | Yes | Yes (if febrile respiratory illness present) |
| Tracheal intubation | Yes | Yes | Yes (if febrile respiratory illness present) |
| Oral or nasal suctioning | Yes | Yes | Yes (if febrile respiratory illness or vomiting present) |
| Controlling arterial or heavy venous hemorrhage | Yes | Yes | Yes |
| Emergency childbirth | Yes | Yes | Yes |
| Known infection or colonization with antibiotic‐resistant organism (VRE, MRSA, etc.) | Yes | No (unless cough present) | Yes |
| Disinfecting or cleaning contaminated equipment or transport vehicle | Yes | Yes | Yes |
| When in doubt: always use the maximum, not the minimum, PPE | |||
a If an aerosol‐generating medical procedure is anticipated or the patient is known to have a communicable disease that is known to be spread by the airborne route, an N95 respirator is the preferred mask to be worn by personnel treating or in close proximity to the patient.
Table 23.2 Suggested Precautions Based on Suspected Infection
| Level 1a | Level 2b | Level 3c |
|---|---|---|
| Abscesses | Chicken pox | AIDSd |
| Diarrhea | Common cold | Clostridium difficile e |
| Hepatitis A | Croup | Hepatitis Bd |
| Hepatitis E | Diphtheria | Hepatitis Cd |
| Cytomegalovirus | Epiglotitis | Hepatitis Dd |
| Herpes simplex | German measles (rubella) | Coronavirusesf during known outbreaks or when virus known to be producing rapid person‐to‐person spread |
| Herpes zoster | Red measles | Influenza (if contact with respiratory secretions is likely) |
| Lice | Herpes zoster | Viral hemorrhagic feversg (Ebola, Marburg, Crimean‐Congo, Lassa) |
| Viral meningitis | Infectious mononucleosis | |
| Scabies | Meningitis, meningococcal | |
| Syphilis | Meningitis, Haemophilus influenza | |
| Mumps | ||
| Pharyngitis | ||
| Pneumonia | ||
| Streptococcus | ||
| Tuberculosis | ||
| Whooping cough |
a Gloves and handwashing.
b Level 1 plus mask (N95 if airborne or high‐risk pathogen) and full face shield.
c Level 2 plus disposable impermeable gown.
d Level 3 if exposure to blood or body fluid is anticipated; otherwise, Level 1 precautions are appropriate.
e Level 2 is adequate is there is no risk of soiling clothes or uniform. However, if the patient has any risk of soiling, Level 3 precautions are necessary.
f Although transmission of coronaviruses (SARS, MERS, COVID‐19) may be considered to be similar to other highly contagious viral agents listed requiring Level 2 precautions, these viruses require Level 3 precautions, particularly in outbreak situations. In addition, special precautions may be required when transporting patients with coronaviruses.
g Special precautions are required when transporting patients who are symptomatic with known of suspected viral hemorrhagic fevers.
Annual vaccination is the best way to prevent influenza, because vaccination can be given well before influenza virus exposures occur and can provide safe and effective immunity throughout the influenza season. Influenza vaccine is the principal means of preventing morbidity and mortality. The vaccine changes yearly based on the antigenic and genetic composition of circulating strains of influenza A and B found in January to March, when influenza