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Unusual Nosocomial Exposure to HINI Influenza Virus via Open-Chest Cardiac Massage

To the Editor—During the "fall wave" of the "swine" HlNl influenza pandemic, there was an increase in the number of cases in the New York area, compared with the initial "herald wave" after the pandemic began in the spring of 2009.' As expected, with an increase in the number of cases during the pandemic, the potential for nosocomial transmission increased. As during the herald wave of the HlNl influenza pandemic, the greatest risk to healthcare workers (HCWs) in terms of nosocomial transmission of HlNl influenza virus was a failure to recognize patients with potential HlNl influenza, resulting in a delay in the institution of influenza precautions. Nosocomial transmission of HlNl influenza virus occurred during the herald wave of the pandemic and either was due to a delayed recognition of HlNl influenza, such that patients were not placed on influenza precautions, or was due to suboptimal adherence to influenza precautions for hospitalized patients with known HlNl influenza.' We report an unusual exposure of HlNl influenza via a patient with HlNl influenza pneumonia who was undergoing mechanical ventilation. Before the patient died, he experienced cardiac arrest, and open-chest cardiac massage was unsuccessfully used in an attempt to restore cardiac function. During the open-chest cardiac resuscitation, there was a rupture of the lungs, and a paraendotracheal tube leak provided a potential for aerosolization or droplet transmission of the HlNl influenza virus. A 36-year-old man had been transferred to our hospital (Winthrop-University Hospital, Mineola, New York) from another hospital. The patient had a history of upper respiratory tract symptoms. Two days before the transfer, the patient had a sudden onset of fever (temperature, 38.9°C [102°F]), as well as nonproductive cough, shortness of breath, and diffuse myalgias. At the time of admission to Winthrop-University Hospital, the patient's temperature was 40°C (104°F), and he was tachypneic (respiratory rate, 26 breaths/minute). His clinical condition rapidly deteriorated, resulting in respiratory failure that required intubation and mechanical ventilation. Because the patient's rapid influenza A (Quick Vue A/B; Quidel) test result was negative, he was not placed on influenza precautions. A nasopharyngeal swab specimen was obtained for reverse-transcription polymerase chain reaction (RT-PCR) for HlNl influenza. Although the patient had no chest pain, he underwent a right heart catheterization because of unexplained tachycardia. He had elevated right-side pressures, an ejection fraction of 5%-10%, and a moderately sized pericardial effusion with cardiac tamponade. At this time, a left ventricular assist device was inserted. After the patient had died, the RT-PCR results for HlNl influenza were reported as positive. The patient's clinical course was complicated by multiple cardiac arrests, requiring emergent pericardiocentesis and thoracotomy for cardiac massage. Measures to resuscitate him were unsuccessful, and he died of fulminant HlNl influenza pneumonia. The patient had not received oseltamivir prophylaxis and had not received the HlNl influenza vaccine. HCWs who were in close contact with the patient were potentially exposed to HlNl influenza virus. At Winthrop-University Hospital, HCWs who engage in intubation and cough-inducing procedures use N95 respirator masks and face shields to protect against exposure to aerosols or droplets. In the case presented, aerosol or droplet exposure occurred under extraordinary circumstances (ie, lung rupture, paraendotracheal tube leaks, and open-chest cardiac massage). A total of 32 HCWs were potentially exposed to HlNl influenza virus. In the cardiac catheterization laboratory, 13 HCWs were exposed. In the medical intensive care unit, 10 HCWs were potentially exposed. Also, 9 additional HCWs were exposed in the operating room. All 32 HCWs were given oseltamivir prophylaxis. Of these 32 HCWs, 2 developed an influenza-like illness but not HlNl influenza. We describe an unusual potential exposure of HCWs to HlNl influenza in the cardiac catheterization laboratory, medical intensive care unit, and operating room where we treated a patient with HlNl influenza. Because this potential mass HCW exposure occurred on a weekend, all exposed HCWs could not immediately be contacted for oseltamivir prophylaxis. Oseltamivir prophylaxis for HlNl influenza was given to all 32 of our potentially infected HCWs during the first 72 hours after exposure. As with other HCW exposures to HlNl influenza virus, the large number of HCWs exposed necessitated a time-consuming, extensive contact investigation by the Infection Control and Employee Health Service. Most fatal cases of HlNl influenza pneumonia in young/ healthy hosts are sue to severe hypoxemia and not bacterial pneumonia' This case is noteworthy, because the HCWs' exposures occurred under extraordinary circumstances (ie, in the context of lung rupture, paraendotracheal tube leak, and open-chest cardiac massage). During HlNl influenza pandemics, if critically ill patients present with an influenza-like illness, influenza precautions (contact or droplet) should be instituted immediately, regardless of the results of rapid influenza diagnostic tests.'