U.S. Department of Labor | ||||||
Occupational Safety & Health Administration |
Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers
Occupational Safety and Health Administration U.S. Department of Labor OSHA 3328-05 2007 Employers are responsible for providing a safe and healthful workplace for their employees. OSHA's role is to assure the safety and health of America's working men and women by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual process improvement in workplace safety and health. This publication is in the public domain and may be reproduced, fully or partially, without permission. Source credit is requested, but not required. This information is available to sensory impaired individuals upon request. Voice phone: (202) 693-1999; teletypewriter (TTY) number: (877) 889-5627. Edwin G. Foulke, Jr.
Contents [Introduction] [References] [Influenza: Clinical Background Information] [Clinical Presentation of Influenza] [Clinical Presentation of Seasonal Influenza] [Clinical Presentations of Prior Influenza Pandemics] [Clinical Presentation of Highly Pathogenic Avian Influenza in Humans] [Diagnosis] [Clinical Diagnosis of Seasonal Influenza] [Laboratory Diagnosis of Seasonal Influenza] [Clinical Diagnosis of Pandemic Influenza] [Laboratory Diagnosis of Avian and Pandemic Influenza] [Modes of Transmission] [Seasonal Influenza Transmission] [Pandemic Influenza Transmission] [Treatment and Prevention] [Seasonal Influenza Treatment and Prevention] [Pandemic Influenza Treatment and Prevention] [References] [Infection Control] [Standard Precautions and Transmission-Based Precautions] [Standard Precautions] [Contact Precautions] [Droplet Precautions] [Airborne Precautions] [Compliance with Infection Control] [Hand Hygiene Compliance] [Respiratory Protection Compliance] [Organizational Factors that Affect Adherence to Infection Control] [Facility Design, Engineering, and Environmental Controls] [Facility Capacity] [Engineering Controls in Improvised Settings] [Airborne Infection Isolation Rooms] [Engineering Controls for Aerosol-Generating Procedures for Patients with Pandemic Influenza] [Cohorting] [Engineering Controls in Diagnostic and Research Laboratories] [Autopsy Rooms for Cases of Pandemic Influenza] [Administrative Controls] [Respiratory Hygiene/Cough Etiquette] [Pandemic Influenza Specimen Collection and Transport] [Patient Transport within Healthcare Facilities] [Pre-Hospital Care and Patient Transport Outside Healthcare Facilities] [Staff Education and Training] [Care of the Deceased] [Patient Discharge] [Visitor Policies] [Healthcare Worker Vaccination] [Antiviral Medication for Prophylaxis and Treatment in Healthcare Workers] [Occupational Medicine Services] [Worker Protection] [Recommendations for Occupational Health Administrators] [Occupational Medical Surveillance and Staffing Decisions] [Personal Protective Equipment] [Gloves] [Gowns] [Goggles/Face Shields] [Respiratory Protection for Pandemic Influenza] [PPE for Aerosol-Generating Procedures] [Order for Putting on and Removing PPE] [Work Practices] [Hand Hygiene] [Other Hygienic Measures] [Facility Hygiene-Practices and Polices] [Laboratory Practices] [References] [Pandemic Influenza Preparedness] [Healthcare Facility Responsibilities During Pandemic Alert Periods] [Healthcare Facility Responsibilities During Pandemic Alert Periods (HSC Stages 0, 1)] [Healthcare Facility Responsibilities During the Pandemic (HSC Stages 2-5)] [Healthcare Facility Recovery and Preparation for Subsequent Pandemic Waves (HSC Stage 6)] [Incorporating Pandemic Plans into Disaster Plans] [Pandemic Planning for Support of Healthcare Worker Staff] [Define Essential Staff and Hospital Services] [Human Resources] [Information Technology] [Public Health Communications] [Surveillance and Protocols] [Psychological Support] [Occupational Health Services] [Developing and Providing Employee Screening for Influenza-Like Illness] [Developing and Providing Immunization and Treatment Strategies] [Continuing Baseline Occupational Health Services] [Training] [Security] [Stockpiles of Essential Resources] [Pandemic Influenza Vaccine] [Antiviral Medication] [Personal Protective Equipment] [Outpatient Services and Clinics] [Alternate Care Sites] [References] [OSHA Standards of Special Importance] [Respiratory Protection Standard 29 CFR 1910.134] [Personal Protective Equipment Standard - 29 CFR 1910.132] [Bloodborne Pathogens Standard - 29 CFR 1910.1030] [General Duty Clause] [References] [Appendix A Pandemic Influenza Internet Resources] [Appendix B Infection Control Communication Tools for Healthcare Workers] [Appendix B-1 Factors Influencing Adherence to Hand Hygiene Practices] [Appendix B-2 Elements of Healthcare Worker Educational and Motivational Programs] [Appendix B-3 Strategies for Successful Promotion of Hand Hygiene in Hospitals] [Appendix B-4 Pandemic Influenza Precautions for Veterans Administration Healthcare Facility Staff] [Appendix B-5 Public Health Measures Against Pandemic Influenza for Individuals, Healthcare Providers, and Organizations] [Appendix C Implementation and Planning for Respiratory Protection Programs in Healthcare Settings] [Appendix C-1 Respiratory Protection Programs] [Appendix C-2 Readiness Plan for Epidemic Respiratory Infection: A Guideline for Operations for Use by the Dartmouth-Hitchcock Medical Center – Lebanon Campus and the Dartmouth College Health Service] [Appendix D Self-Triage and Home Care Resources for Healthcare Workers and Patients] [Appendix D-1 Sample Self-Triage Algorithm for Persons with Influenza Symptoms] [Appendix D-2 Home Care Guide for Influenza] [Appendix E References for Diagnosis and Treatment of Staff During an Influenza Pandemic] [Appendix E-1 Influenza Diagnostic Table] [Appendix F Pandemic Planning Checklists and Example Plans] [Appendix F-1 Sample Emergency Management Program Standard Operating Procedure (SOP)] [Appendix G Risk Communication Resources] [Appendix G-1 Risk and Crisis Communication: 77 Questions Commonly Asked by Journalists During a Crisis] [Appendix H Sample Supply Checklists for Pandemic Planning] [Appendix H-1 Examples of Consumable and Durable Supply Needs] [Appendix H-2 Suggested Inventory of Durable and Consumable Supplies for Veterans Administration Healthcare Facilities During a Pandemic Influenza] [OSHA Assistance] [OSHA Regional Offices] Introduction A pandemic is a global disease outbreak. A flu pandemic occurs when a new influenza virus emerges for which people have little or no immunity, and for which there is no vaccine. The disease spreads easily person-to-person, causes serious illness, and can sweep across the country and around the world in a very short time. It is difficult to predict when the next influenza pandemic will occur or how severe it will be. Wherever and whenever a pandemic starts, everyone around the world is at risk. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but they cannot stop it. An especially severe influenza pandemic could lead to high levels of illness, death, social disruption, and economic loss. Everyday life would be disrupted because so many people in so many places become seriously ill at the same time. Impacts can range from school and business closings to the interruption of basic services such as public transportation and food delivery. An influenza pandemic is projected to have a global impact on morbidity and mortality, thus requiring a sustained, large-scale response from the healthcare community. The 1918 influenza pandemic was responsible for over 500,000 deaths in the United States, while the 1957 and 1968 pandemic influenza viruses were responsible for 70,000 and 34,000 deaths, respectively. 1 More recently, one modeling study estimated that an influenza pandemic affecting 15 to 35 percent of the United States population could cause 89,000 to 207,000 deaths, 314,000 to 734,000 hospitalizations, 18 to 42 million outpatient visits, and 20 to 47 million additional illnesses. 2 In contrast, from 1990 to 1999, seasonal influenza caused approximately 36,000 deaths per year in the United States. 3 A substantial percentage of the world's population will require some form of medical care. Healthcare facilities can be overwhelmed, creating a shortage of hospital staff, beds, ventilators and other supplies. Surge capacity at non-traditional sites such as schools may need to be created to cope with the demand. It is expected that such an event will quickly overwhelm the healthcare system locally, regionally, and nationally. 4 An increased number of sick individuals will seek healthcare services. In addition, the number of healthcare workers available to respond to these increased demands will be reduced by illness rates similar to pandemic influenza attack rates affecting the rest of the population. Finally, healthcare workers and healthcare resources will also be expected to continue to meet non-pandemic associated healthcare needs. In order to mitigate the effects of an influenza pandemic on the healthcare community, it is important to identify healthcare providers and recognize the diversity of practice settings.
The guidance document is organized into four major sections:
The document also contains appendices which provide pandemic planners with samples of infection control plans, examples of practical pandemic planning tools and additional technical information. Topic areas include Internet resources, communication tools, sample infection control programs, self-triage and home care resources, diagnosis and treatment of staff during a pandemic, planning and supply checklists and risk communication. This educational material has been provided for informational purposes only and should be used in conjunction with the entire document in order to ensure that healthcare workers are adequately protected during a pandemic. OSHA does not recommend one option over the many effective alternatives that exist. OSHA has prepared additional, general information to assist workplaces in their preparation for an influenza pandemic entitled, Guidance on Preparing Workplaces for an Influenza Pandemic which is available at www.osha.gov. [Table of Contents] References
Influenza: Clinical Background Information Historically, influenza has caused outbreaks of respiratory illness for centuries, including three pandemics (worldwide outbreaks of disease) in the 20th century. 1 There are three types of influenza viruses: types A, B, and C. Only type A influenza viruses cause pandemics. Seasonal influenza outbreaks can be caused by either type A or type B influenza viruses. Influenza type C viruses cause mild illness in humans but do not cause epidemics or pandemics. This guidance is aimed at protecting healthcare workers in the event of an influenza pandemic; therefore, the focus will be on the characteristics of type A influenza viruses. Of the three types of influenza viruses, only type A is divided into subtypes. Subtype designations are based on the presence of two viral surface proteins (antigens): hemagglutinin (H) and neuraminidase (N). To date, 16 different hemagglutinin and 9 different neuraminidase surface proteins have been identified in influenza A viruses. 2 Subtypes are designated as the H protein type (1–16) solely or followed by the N protein type (1–9) (e.g., H5N1). Three different subtypes (i.e., H1N1, H2N2, and H3N2) have caused pandemics in the 20th century. Influenza A viruses vary in virulence, infectivity to specific hosts, modes of transmission, and the clinical presentation of infection. Seasonal, avian, and pandemic influenza can occur in humans. It is important to have a basic understanding of the terms seasonal, avian and pandemic influenza in order to appreciate the guidance in this document.
As of November 2006, the spread of highly pathogenic H5N1 avian influenza virus from person to person has been limited to rare, sporadic cases. Nonetheless, because all influenza viruses have the ability to change, scientists are concerned that highly pathogenic H5N1 avian influenza virus one day could be able to sustain human-to-human transmission. Because these viruses do not commonly infect humans, there is little or no immune protection against them in the human population. If the highly pathogenic H5N1 avian influenza virus were to gain the capacity to sustain transmission from person to person, a pandemic could begin.
The first two phases of the WHO Pandemic Alert System comprise the "Inter-pandemic Period" in which there is a novel influenza A virus in animals, but no human cases have been observed. Phase 2 indicates that an animal influenza subtype that poses a risk to humans has been detected. The next three phases (Phases 3–5) compose the "Pandemic Alert Period" in which a novel influenza virus causes human infection with a new subtype, but does not exhibit efficient and sustained human-to-human transmission. Once a new influenza A virus develops the capacity for efficient and sustained human-to-human transmission in the general population (Phase 6), the WHO declares that an influenza pandemic is in progress (this is known as the "Pandemic Period"). For additional information visit WHO's Epidemic and Pandemic Alert and Response website at http://www.who.int/csr/disease/avian_influenza/phase/en/index.html. Federal government response stages to these WHO phases are described in the National Strategy for Pandemic Influenza: Implementation Plan which can be found at http://www.whitehouse.gov/homeland/pandemicinfluenza-implementation.html. [Table of Contents] Clinical Presentation of Influenza It may be useful for healthcare providers to be aware of the clinical presentation of seasonal influenza, prior influenza pandemics, and highly pathogenic avian influenza in humans to assist them when evaluating patients who present with influenza-like illness. The clinical picture of influenza infections can vary from no symptoms at all in seasonal influenza to fulminant (fully symptomatic) disease in pandemic strains that result in severe illness and death, even among previously healthy adults and children. 4 Fever and respiratory symptoms are characteristic of all forms of influenza. The Centers for Disease Control and Prevention's (CDC's) Sentinel Provider Network (SPN) monitors influenza timing and severity. The SPN 5 is comprised of approximately 2,300 primary care providers that provide weekly reports on outpatient "influenza-like illnesses" to state health departments and to the CDC. The SPN uses "fever >100° F or 37.8° C and sore throat and/or cough in the absence of a known cause other than influenza" as its definition of influenza-like illness. [Table of Contents] Clinical Presentation of Seasonal Influenza Seasonal influenza typically has an abrupt onset, with symptoms of fever, chills, fatigue, muscle aches, headache, dry cough, upper respiratory congestion, and sore throat. 6 The time from exposure to disease onset is usually 1 to 4 days, with an average of 2 days. Most patients recover within 3 to 7 days. 7 In adults, fevers usually last for 2 to 3 days, but may last longer in children. Cough and weakness can persist for up to 2 weeks. Except for fever, the physical examination has few specific findings. Typically there is weakness and mild inflammation of the upper respiratory tract. Routine outpatient laboratory findings are also non-specific. Available laboratory tests that are specific for influenza are described in the Diagnosis section on page 9 of this document. Adults are possibly infectious from about 1 day before until about 5 days after the onset of clinical illness. Children and the immunocompromised (e.g., people with HIV infection, organ transplantation or receiving chronic steroids) have a much longer period of infectivity. Children can be infectious for 10 or more days, and young children can shed the virus for several days before the onset of illness. Severely immunocompromised persons can shed the virus for weeks or months. 7 Seasonal influenza is responsible for approximately 36,000 deaths and 226,000 hospitalizations annually in the United States. 8 The risk of death is highest among the elderly, the very young, and patients with cardiopulmonary and other chronic conditions. 7 [Table of Contents] Clinical Presentations of Prior Influenza Pandemics The 1918 influenza pandemic, caused by subtype H1N1 viruses, had signs and symptoms of far greater severity than seasonal influenza. It resulted in death for an estimated 500,000 U.S. citizens and as many as 40 million people worldwide. The 1918 pandemic disproportionately affected young, healthy adults, between the ages of 15 and 35. A significant proportion of patients developed fulminant disease, accompanied by a striking perioral cyanosis, leading to death within a few days. Postmortem examinations in these patients frequently revealed denuding tracheobronchitis, pulmonary hemorrhage, or pulmonary edema. Others survived the initial illness, only to die of a secondary bacterial pneumonia. 6 The 1957 (caused by subtype H2N2 viruses) and 1968 (caused by subtype H3N2 viruses) influenza pandemics killed an estimated 70,000 and 34,000 U.S. citizens, respectively. 8 The clinical features of the pandemics of 1957 and 1968 were also typical of influenza-like illness, including fever, chills, headache, sore throat, malaise, cough, and coryza, but were milder compared to the 1918–19 pandemic. 6 The 1957 influenza pandemic was notable for severe complications, such as primary viral pneumonia, particularly in pregnant women. As in the pandemic of 1918, some people survived the initial viral infection, only to later die of a secondary bacterial pneumonia. [Table of Contents] Clinical Presentation of Highly Pathogenic Avian Influenza in Humans The highly pathogenic H5N1 avian influenza virus that caused outbreaks in Hong Kong, Thailand, Vietnam, and Cambodia, like the 1918 pandemic virus, primarily resulted in disease in children and young adults. 9 Hospitalized patients initially developed typical seasonal influenza symptoms such as high fever and cough, but unlike seasonal influenza, there were lower respiratory tract rather than upper respiratory tract symptoms. Because of the involvement of the lower respiratory tract, patients typically had shortness of breath and almost all patients had developed viral pneumonia at the time of hospitalization. Also unlike typical seasonal influenza, diarrhea, abdominal pain, and vomiting were frequently reported. Common laboratory findings were lymphopenia, thrombocytopenia and elevated aminotransferase levels. As of November 13, 2006, highly pathogenic H5N1 viruses had not been detected in animals or humans in the United States. For up-to-date information regarding the number of human cases of avian influenza and deaths worldwide, visit the WHO Confirmed Cases of Human Influenza A (H5N1) website at http://www.who.int/csr/disease/avian_influenza/country/en/. An outbreak of another avian influenza virus, H7N7, occurred among poultry farm employees and those helping to contain the outbreak in the Netherlands in 2003. 10 The clinical course of this influenza virus was unusual in that conjunctivitis was a common finding and fewer affected persons had respiratory symptoms, although the one fatality among the 89 human cases was associated with respiratory disease. No further outbreaks were reported through April 24, 2006 (http://www.cdc.gov/flu/avian/gen-info/avian-flu-humans.htm). [Table of Contents] Diagnosis Accurate and timely influenza diagnosis requires knowledge of the likely clinical presentations of seasonal influenza and of any circulating strains of novel viral subtypes, an awareness of the risks for exposure, and knowledge of the capabilities and limitations of laboratory diagnostic tests. The more quickly a new pandemic virus can be identified, the sooner actions can be taken to isolate the initial cases and initiate other public health measures to prevent spread through the community andthe sooner infection control measures can be implemented to protect the community's health-care workers. [Table of Contents] Clinical Diagnosis of Seasonal Influenza Uncomplicated seasonal influenza presents as a sudden onset of fever and respiratory illness with muscle aches, headaches, nonproductive cough, sore throat, and runny nose. Children can also have ear infections and/or gastrointestinal symptoms. 7 The diagnosis of the influenzas will be primarily through recognizing symptom complexes such as those used in surveillance. The SPN definition for influenza-like illness is used for seasonal influenza surveillance. 5 However, this definition is not specific and may share features with other respiratory illnesses present in the community. The likelihood of a clinical sign or symptom to accurately detect influenza infection in a group of patients is called sensitivity. Conversely, the likelihood of a clinical sign or symptom to exclude influenza infection in a group of patients who do not have influenza is called specificity. Both the sensitivity and specificity of clinical signs and symptoms of influenza infection vary with multiple factors, including patient age, vaccination status, hospitalization status, degree of co-circulation of other infectious agents that cause respiratory symptoms in the community, and the percentage of the population infected with influenza (prevalence). The clinical signs and symptoms of influenza have been studied using viral cultures as the criteria for definitive influenza diagnosis in groups of mostly young adults when influenza was circulating in their community. It has been reported that the use of the influenza-like case definition is 63 to 78% accurate in identifying culture-confirmed cases of influenza (a sensitivity of 63 to 78%) and 55 to 71% accurate in excluding influenza (specificity of 55 to 71%). 7 The sensitivity and specificity will vary based on the percentage of all respiratory illnesses that are due to influenza. Other studies have addressed influenza signs and symptoms in different groups. 11, 12 There is considerable overlap in the clinical presentation of seasonal influenza and other viral and bacterial respiratory infections. Influenza surveillance case definitions and laboratory testing can assist in differentiating among these infections. However, clinicians must always maintain a level of awareness that co-infections with bacterial respiratory infections or non-influenza viruses can occur with seasonal influenza. Clinical judgment regarding diagnosis and treatment is needed in conjunction with laboratory testing in order to differentiate between potential infectious organisms. [Table of Contents] Laboratory Diagnosis of Seasonal Influenza During Inter-pandemic and Pandemic Alert Periods, use of laboratory diagnostic tests for influenza supports seasonal influenza surveillance and provides laboratory detection of novel influenza subtypes. There are multiple laboratory techniques for identifying influenza viruses, including the rapid antigen test, the reverse transcriptase polymerase chain reaction (RT-PCR) assays, virus isolation, and immunofluorescence antibody assays. 13 When respiratory secretions are used for seasonal influenza diagnosis, nasopharyngeal samples are more likely to yield a positive result than are pharyngeal swab samples. 14 Commercial rapid testing can detect influenza virus in less than 30 minutes. However, some of these tests are not very sensitive 9 (false negative results are common) and not all of these tests are able to distinguish between influenza A and B viruses (see Safety Tips for Laboratorians: Cautions in Using Rapid Tests for Influenza A Viruses at http://www.fda.gov/cdrh/oivd/tips/rapidflu.html). When influenza is suspected during an outbreak of respiratory illness, both rapid testing and viral cultures should be done. Although viral cultures require five days or more to perform, they can provide specific information on the strain and subtype of the influenza virus tested, and provide information on the sensitivity to antiviral medication as well. 14 The HHS/CDC Influenza (Flu) Laboratory Diagnostic Procedures for Influenza website (http://www.cdc.gov/flu/professionals/labdiagnosis.htm) maintains a table of the available diagnostic tests for the influenza virus. 14 [Table of Contents] Clinical Diagnosis of Pandemic Influenza Patients with pandemic influenza will likely have clinical signs and symptoms similar to seasonal influenza, although the clinical presentation and course of illness may be severe in a higher percentage of the cases of pandemic influenza. In general, if the next pandemic is comparable to the 1918 Type A H1N1 virus, the pandemic influenza is likely to be far more severe than seasonal influenza, and might disproportionately affect a younger population. An important factor to look for when evaluating patients for the presence of pandemic influenza during all phases of a WHO Pandemic Alert Period, when human infection with a new subtype is detected, is a possible source of exposure. For instance, the current sources of exposure to highly pathogenic H5N1, the avian influenza virus of most concern, would likely involve international travel or occupational exposure to infected poultry or wild birds. Emergency room physicians and other healthcare personnel interviewing patients with influenza-like illness should ask about recent travel history. A patient who has a history of travel to a country affected by a novel influenza virus and who has the onset of influenza-like illness within the known incubation period for that virus should be suspected to be infected with the novel influenza virus. Seasonal influenza incubation is usually 1 to 4 days, but novel influenza viruses may have longer incubation periods, possibly up to 10 days. 6 A frequently updated report of countries that have had human infections with highly pathogenic H5N1 avian influenza viruses is available at the WHO Web website at http://www.who.int/csr/disease/avianinfluenza/en/. Individuals who handle or process animals with a novel virus, laboratory personnel who analyze specimens containing a novel virus and healthcare workers who care for patients infected with a novel virus are at risk for contracting that viral infection. If the virus of concern has not yet been shown to be capable of sustained human-to-human transmission, occupational risk would be higher for employees with exposure to animal or animal products. 6 [Table of Contents] Laboratory Diagnosis of Avian and Pandemic Influenza Currently, the highly pathogenic H5N1 avian influenza virus is considered to have the greatest potential for mutation to a pandemic virus given how widespread the virus is and because it has already caused illness and death in people. This virus has spread rapidly in bird populations throughout Asia, Europe, and Africa. Recently, HHS/CDC developed a 4-hour RT-PCR assay for the detection of the gene coding for the H5 surface protein of the Asian lineage of the highly pathogenic H5N1 avian influenza virus. 15 These RT-PCR reagents have been distributed to approximately 140 designated laboratories of the Laboratory Response Network (LRN) which has laboratories located in all 50 states. 15 The RT-PCR testing should be done when a patient has severe respiratory illness and clinical or epidemiological risk. Clinicians should contact their local or state health department as soon as possible to report any suspected human case of influenza H5N1 in the United States. Positive tests for influenza A H5N1 in the United States should be confirmed by HHS/CDC, which has been designated as a WHO H5 Reference laboratory. An HHS/CDC guidance document Updated Interim Guidance for Laboratory Testing of Persons with Suspected Infection with Avian Influenza A (H5N1) Virus in the United Statesis distributed via the Health Alert Network (HAN) at http://www2a.cdc.gov/han/ArchiveSys/ViewMsgV.asp?AlertNum=00246. Tests for other avian viruses with pandemic potential are also being developed. [Table of Contents] Modes of Transmission Information on the mode of seasonal influenza transmission is based on previous influenza outbreaks. However, the transmission characteristics of a pandemic influenza virus will not be known until after the pandemic begins. This section covers the transmission patterns of seasonal influenza and past and potential pandemic influenza outbreaks. [Table of Contents] Seasonal Influenza Transmission The usual method of seasonal influenza transmission is assumed to be through coughs and sneezes of infected persons within close proximity. A susceptible person may develop symptoms within 1 to 4 days after exposure to an infected patient who is shedding the influenza virus. The newly infected person is then infectious for about 6 days, usually beginning 1 day prior to the onset of symptoms. This varies with age and disease, as discussed previously. The relative importance of the various routes of transmission is not known, although it is now commonly accepted that the spread of seasonal influenza requires close proximity-via exposure to large droplets (droplet transmission), direct contact (contact transmission), or near range exposure to aerosols. 16 The term "near range" is used to differentiate influenza airborne transmission from the long-range airborne transmission seen in diseases such as tuberculosis, where disease spread can occur over long distances and prolonged periods of time. Droplet Transmission Epidemiologic patterns suggest that droplet transmission is a major route of influenza spread. Susceptible individuals are subject to infection by large particle droplets from infected patients. Droplets are produced by coughing, sneezing, or talking, or by therapeutic manipulations such as suctioning or bronchoscopy. Infected droplets may enter the susceptible individual through the conjunctiva of the eye or the mucus membranes of the mouth or nose. Droplets travel only about 3 feet and do not remain in the air, so special ventilation procedures and advanced respiratory protection is not required to prevent this type of transmission. 16 Airborne Transmission Airborne transmission, as occurs in tuberculosis, is spread through small infectious particles such as droplet nuclei. 17 Unlike the larger droplets, these very small airborne droplet nuclei can be readily disseminated by air currents to susceptible individuals. They can travel significant distances and can penetrate deep into the lung to the alveoli where they can establish an infection. The presence of significant airborne transmission would indicate the need for ventilation procedures and respiratory protection greater than that afforded by a surgical mask, e.g., a NIOSH-certified N95 or higher respirator. No study has definitively established airborne transmission as a major route of influenza transmission, but multiple studies suggest that some airborne influenza transmission may occur. Experiments in mice have demonstrated that air exchange can decrease influenza virus transmission, and have demonstrated infectious particles that are smaller than ten microns. 18 A ferret study demonstrated that influenza virus transmission can occur through a vent with right angles. A human volunteer study demonstrated that, when a small droplet aerosol is used, influenza transmission can occur with lower virus concentrations. 19 Another human observational study documented the spread of influenza to 72 percent of the passengers and crew on an airplane with a ventilation system that was not functioning for 3 hours. 20 While these studies suggest that airborne influenza transmission occurs under certain conditions, the proportion of influenza illness resulting from this route of transmission is unknown. Contact Transmission Contact transmission can be direct or indirect. Direct contact transmission occurs by touching skin to skin, usually during direct patient care activities such as turning or bathing patients, or by shaking hands. Indirect transmission occurs when infected material from the patient is deposited in the environment and is taken up by a susceptible individual. 16 There is limited data on the survivability of influenza A and B viruses outside of the human host. One study, 21 conducted by Bean et al., suggests that that if a heavily infected person contaminated a stainless steel surface, there might be enough viable viral particles remaining after 2-8 hours to allow contact transmission to a susceptible person. It should be noted that this study was conducted at a relative humidity of 35 to 40 percent, a level that favors the survival of influenza viruses. Other studies have clearly demonstrated that humidity plays a significant role in influenza viral survival with survival times being longer at lower humidity. Further research is needed to more fully appreciate the role of contact transmission for various strains of influenza and the effect of varying environmental conditions. Although it is assumed that influenza spreads by contact transmission, the proportion of spread that occurs through this mechanism is unknown. 16 [Table of Contents] Pandemic Influenza Transmission This section discusses observational studies on human-to-human transmission during previous influenza pandemics and observations about implications for transmission of current avian influenza virus infections that are of concern for possible future influenza pandemics. Transmission, Past Pandemics One influenza transmission study conducted during the 1957 pandemic indicated the importance of person-to-person spread while another suggested the apparent importance of airborne transmission. The first study, an epidemiological study demonstrated influenza transmission from a newly hospitalized, infected patient who had no isolation precautions to three healthcare workers and one adjacent patient. Ultimately, 30 of the 62 exposed patients and ward staff became ill. 22 Although the authors did not address the likely mode of transmission, a later analysis of the data was interpreted as not consistent with a single source pattern as would be seen in airborne transmission. 17 The second study, an observational influenza transmission study during the 1957 pandemic conducted at a Veterans Administration Hospital suggested airborne transmission. The study compared the influenza illness rates in tuberculosis patients in wards with and without ultraviolet ceiling lights and found rates of 2 percent and 19 percent, respectively. The authors of this study suggest this finding implies that transmission of influenza was significantly blocked by radiant (UV) disinfection of droplet nuclei. 23 Transmission, Possible Future Pandemics The influenza viruses that are currently of greatest concern for possible future pandemics are the highly pathogenic avian influenza viruses, most notably strains of H5N1 and H7N7, which have caused outbreaks among humans. A summary of the clinical features of hospitalized patients with highly pathogenic H5N1 avian influenza described a clinical course that differed from seasonal influenzas. The highly pathogenic H5N1 avian influenza had an initial presentation with lowerrespiratory tract symptoms and viral pneumonia (seasonal influenzas present more often with upper respiratory symptoms), a higher ribonucleic acid detection in pharyngeal samples (seasonal influenzas have higher viral detection in nasal samples), and more frequent diarrhea, abdominal pain, and vomiting. The detection of infectious virus and ribonucleic acid in the blood, cerebrospinal fluid (CSF) and feces of one patient, a child, 9 raises concern that transmission of this virus may be possible by contact with blood, CSF and feces in addition to respiratory secretions, but this remains unknown. An outbreak of highly pathogenic H7N7 avian influenza virus occurred in poultry farm employees in the Netherlands in 2003. 10 This influenza's clinical course was unique in that it was mainly associated with conjunctivitis. Seasonal influenza transmission is considered to take place primarily through the respiratory tract, but the conjunctivitis component of highly pathogenic H7N7 avian influenza suggests that its transmission may also occur via the mucous membranes of the eye. [Table of Contents] Treatment and Prevention Treatment and prevention of influenza involves multiple infection control measures, including vaccination, antiviral medications, and management of influenza complications. This section concentrates on immunization and antiviral medications. [Table of Contents] Seasonal Influenza Treatment and Prevention Medications available for influenza A treatment and prophylaxis include the M2 ion channel inhibitors (also known as adamantanes) amantadine and rimantadine and the neuraminidase inhibitors zanamivir and oseltamivir. Presently, only the neuraminidase inhibitors are available for treatment and prophylaxis of both influenza A and B. Current HHS/CDC drug recommendations, announced during the 2005-2006 influenza season (see http://www.cdc.gov/flu/han011406.htm), advise against the use of adamantanes for seasonal influenza due to resistance. Therefore, the neuraminidase inhibitors oseltamivir and zanamivir are the only drugs currently recommended for treatment and prophylaxis of influenza. Neuraminidase inhibitors are prescription drugs and they are most effective for treatment when use begins within two days of symptom onset. Clinicians should adhere to HHS/CDC recommendations regarding the use of antivirals. 24 Antiviral medications can be used to prevent influenza, but the primary strategy for preventing influenza infections is vaccination. Vaccines are available in two forms: 1) as an intranasal live attenuated vaccine and 2) as an injectable, inactivated trivalent vaccine. Indications and contraindications differ among the preparations. 25 Annual vaccination has been shown to reduce the incidence of influenza infections in healthcare workers. 25, 26, 27 Infection control measures are another means to prevent infection, but their benefit is less well established. [Table of Contents] Pandemic Influenza Treatment and Prevention The appropriate use of antiviral drugs during a pandemic could reduce mortality and morbidity. At the time of this writing, HHS recommendations for treatment of novel viruses are to use the neuraminidase inhibitors zanamivir and oseltamivir because of influenza resistance to amantadine and rimantadine. 24 Although the magnitude of drug effect against infections with novel strains cannot be predicted precisely, early use is expected to be important for drug effectiveness. The availability of adequate antiviral supplies during a pandemic is far from certain, and, therefore, the HHS Pandemic Influenza Plan provides antiviral drug use priority recommendations. Healthcare workers are included in the priority group recommendations. 28 A vaccine against a specific pandemic influenza strain will likely not be available until after the pandemic begins. But vaccinations against seasonal influenza during the WHO's Interpandemic and Pandemic Alert Period can reduce co-infections and might ameliorate pandemic effects. HHS recommendations are for enhanced levels of seasonal influenza vaccinations in groups at risk for severe influenza and healthcare workers. In addition, HHS recommends enhanced pneumococcal polysaccharide vaccination for some individuals. 29 A limited amount of H5N1 avian influenza vaccine is being stockpiled. However, as the pandemic virus cannot be predicted, it is unknown if stockpiled vaccine will provide protection against a future circulating pandemic influenza virus. A monovalent vaccine is expected to start becoming available within four-to-six months after identification of a specific pandemic virus strain. As noted above, the HHS Pandemic Influenza Plan recommends that health-care workers be included on the priority list (which has not been fully defined) when the availability of pandemic influenza vaccinations is limited. 28, 29 [Table of Contents] References
Infection Control A successful infection control program for pandemic influenza utilizes the same strategies implemented for any infectious agent, including facility and environmental controls (i.e., engineering controls), standard operating procedures (i.e., administrative controls), personal protective clothing and equipment, and safe work practices. These strategies form the basis of standard precautions and transmission-based precautions. Given that the exact transmission pattern or patterns will not be known until after the pandemic influenza virus emerges, transmission-based infection control strategies may have to be modified to include additional selections of engineering controls, personal protective equipment (PPE), administrative controls, and/or safe work practices. The infection control section of this document includes information about standard precautions and transmission-based precautions as they relate to the protection of healthcare workers. [Table of Contents] Standard Precautions and Transmission-Based Precautions Standard precautions are designed for the care of all patients, regardless of their diagnosis or presumed infection status. Transmission-based precautions are used for patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne, droplet, or contact transmission. Some infectious agents require the application of several types of precautions to prevent transmission. For example, HHS/CDC recommends that standard, contact, and airborne precautions be implemented when caring for patients with varicella infection. 1, 2 Initially designed for the hospital setting, standard precautions and transmission-based precautions can be applied to a variety of healthcare settings, including the outpatient environment, the pre-hospital setting, and alternate care sites. The infectious characteristics of pandemic influenza will not be known until after it emerges. Consequently, infection control plans will have to be adapted to the current knowledge of transmission and updated as new information becomes available. The Department of Health and Human Services (HHS) and its partners will provide updated epidemiologic information and infection control guidance at www.pandemicflu.gov. For a more complete discussion of standard precautions and transmission-based precautions, visit the HHS/CDC Guideline for Isolation Precautions in Hospitals website at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html. [Table of Contents] Standard Precautions Standard precautions should be used for all patients receiving care, regardless of their diagnosis or presumed infection status. Standard precautions apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin; and (4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in healthcare settings. A risk assessment to determine necessary PPE and work practices to avoid contact with blood, body fluids, excretions, and secretions will help to customize standard precautions to the healthcare setting of interest. Standard precautions include:
Implementation and enforcement of all standard precautions, including appropriate use of facial (eyes, nose, and mouth) protection when caring for respiratory patients, should be prioritized in all healthcare facilities in order to mitigate pandemic influenza transmission. [Table of Contents] Contact Precautions In addition to standard precautions, contact precautions are indicated for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. In addition to standard precautions, contact precautions include:
[Table of Contents] Droplet Precautions Droplet precautions are indicated for patients known or suspected to have serious illnesses transmitted by large particle droplets, such as seasonal influenza, invasive Haemophilus influenzae type b disease and invasive Neisseria meningitidis. In addition to standard precautions, droplet precautions include the use of a surgical mask when working within 3 feet of the patient and the placement of the patient in a private room or with patients who have an active infection with the same microorganism but with no other infection (cohorting). Although human seasonal influenza virus is transmitted primarily by contact with infectious droplets, some degree of airborne transmission occurs. Additionally, droplet precautions do not protect healthcare workers from infections resulting from aerosol transmission or during patient care activities that are likely to generate infectious aerosols, such as sputum induction or bronchoscopy. [Table of Contents] Airborne Precautions Airborne Precautions are designed to reduce the risk of airborne transmission of infectious agents. In addition to standard precautions, airborne precautions are used for patients known or suspected to have serious illnesses. Current clinical guidelines recommend that airborne precautions be used for such illnesses as H5N1 avian influenza, severe acute respiratory syndrome (SARS), measles, varicella, and tuberculosis. 1, 5, 6 Airborne precautions include:
For patients for whom influenza is suspected or diagnosed, surveillance, vaccination, antiviral agents, and use of private rooms as much as feasible is recommended. 7 In contrast to tuberculosis, measles, and varicella, the pattern of disease spread for seasonal influenza does not suggest transmission across long distances (e.g., through ventilation systems); therefore, negative pressure rooms are not needed for patients with seasonal influenza. 8 Many hospitals encounter logistic difficulties and physical limitations when admitting multiple patients with suspected influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very least, avoid room-sharing with high-risk patients. For additional information regarding the airborne infection isolation rooms, see the section Airborne Infection Isolation Rooms on page 19. [Table of Contents] Compliance with Infection Control Healthcare administrators should emphasize those aspects of infection control already identified as "weak links" in the chain of infectious precautions- adherence to hand hygiene, consistent and proper use of PPE, and influenza vaccination of healthcare workers. The following section describes factors influencing compliance with infection control measures. Healthcare employers and employees should work together address these factors and enhance compliance with infection control recommendations. [Table of Contents] Hand Hygiene Compliance Although handwashing is well known as a critical factor for infection control, low rates of healthcare worker compliance have been well documented. The HHS/CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), in collaboration with the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Infectious Diseases Society of America (IDSA) reviewed 33 studies from 1981 to 2000. They concluded that adherence of healthcare workers to recommended hand hygiene procedures has been poor, with mean baseline rates of 5 - 81 percent and an overall average of 40 percent. 3 Several factors influence adherence to hand hygiene practices, including
Appendix B contains extended information regarding risk factors for non-compliance with hand hygiene recommendations and strategies for successful promotion of hand hygiene. For a more complete discussion of the recommendations for hand hygiene and the scientific evidence, see the HHS/CDC Guideline for Hand Hygiene in Healthcare Settingsat http://www.cdc.gov/handhygiene/. [Table of Contents] Respiratory Protection Compliance Studies have shown that healthcare worker compliance rates with respiratory protection are highly variable. 9, 10 Healthcare workers fail to wear respirators for a number of reasons, and it is important to understand the nature of this resistance in order to overcome it. The following are the most frequently cited reasons for not wearing respirators: 11
Care Facilities, September 1999, accessible at http://www.cdc.gov/niosh/99-143.html. Initially intended for protection against tuberculosis, the guidance can be adapted to address a variety of infectious pathogens, including pandemic influenza. Healthcare employers should work hard to overcome employee resistance to wearing respirators and promote full compliance with the respiratory protection program. Strategies should be implemented to promote respirator use, such as staff education, reminders in the workplace and routine observation and feedback. [Table of Contents] Organizational Factors that Affect Adherence to Infection Control Lessons from the SARS outbreak showed that the most important factors affecting healthcare worker perceptions of risk and adherence to infection control practices were healthcare workers' perception that their facilities had clear policies and protocols, having adequate training in infection control procedures, and having specialists available. 12 In a study among 1,716 hospital-based healthcare workers, Gershon et al. (1995) found that employees who perceived a strong commitment to safety at their workplace were over 2.5 times more likely to comply with universal precautions. 13 Another study of nurses found that the perception of PPE interference with work was the strongest predictor of failure to comply with universal precautions. 14 The same researchers examined the relative importance of safety climate, the availability of PPE, and individual employee characteristics as determinants of compliance with universal precautions. Safety climate was found to have the greatest association with proper infection control behaviors. 15 Gershon et al. (2000) developed a safety climate scale (46 questions) to measure six different areas of a hospital safety climate:
[Table of Contents] Facility Design, Engineering, and Environmental Controls Engineering controls are the preferred method to reduce transmission of infectious aerosols in areas used to house or evaluate patients with respiratory illness. The appropriate use of engineering controls and other control efforts will require frequent analysis of pandemic influenza transmission patterns in designated wards, in the facility, and in the community. Existing healthcare facility layouts should be evaluated for potential enhancements of infection control. A SARS investigation in Ontario 17 noted that hospitals designed with open, public spaces encountered logistical difficulties and great expense in their efforts to control entry and, therefore, to control introduction of infectious diseases. Hospitals had an inadequate number of isolation rooms and negative pressure rooms. Triage areas were designed to streamline patient flow and enhance patient satisfaction, rather than to prioritize infection isolation or healthcare worker protection. A desirable emergency room design includes a triage area that can be closed off as an isolation area, in the event of inadvertent contamination. Isolation areas should have adjacent rooms for staff to put on and take off scrubs, and to take showers. Facility planning should include storage space for augmented infection control items, including durable goods such as ventilators, portable high-efficiency particulate air (HEPA) filtration units, portable x-ray units, and respirators. Thoughtful facility design includes rest and recuperation sites for responders. These sites can be stocked with healthy snacks and relaxation materials (e.g., music and movies), as well as pamphlets or notices about workforce support services. [Table of Contents] Facility Capacity An influenza pandemic may increase the demand for hospital inpatient and intensive care unit beds and assisted ventilation services by more than 25 percent. 18 Toronto clinicians reported that the intensive care unit capacity was a key factor that determined the number of SARS patients that could be managed. It was determined that approximately 20 percent of SARS patients required intensive care; therefore, a maximum number of SARS patients per facility could be calculated. 19 HHS/CDC provided instructions that allow public health officials to estimate the demand for hospital resources and to estimate the number of deaths, both for a 1968-type of influenza pandemic and for a 1918-type of pandemic. 20 FluAid 2.0 and FluSurge 2.0 software estimate the number of deaths, hospitalizations, outpatient visits, and the increased demand for hospital resources (e.g., beds, intensive care, or ventilators for both scenarios). For additional information see Appendix A. Alternate care sites may be developed at federal or state discretion to ease the burden of care on healthcare facilities. For additional information regarding alternate care sites, see section Alternate Care Sites on page 47. [Table of Contents] Engineering Controls in Improvised Settings Infectious disease and disaster management experts have predicted the need to use schools, stadiums, and other converted settings in the event of a pandemic that results in severe disease. The National Strategy for Pandemic Influenza 21 calls for communities to anticipate large-scale augmentation of existing healthcare facilities. During the SARS outbreak of 2004, the North York General Hospital in Toronto converted two nearly constructed hospital wings into SARS wards. Additionally, a tent clinic was built on an ambulance loading dock to triage the general public presenting with possible SARS. A more detailed description of the converted healthcare settings, including the implementation of engineering of controls, is available in Loutfy et al. 2004. 19 [Table of Contents] Airborne Infection Isolation Rooms Although the need to isolate patients with highly pathogenic infections is a central tenet of infection control, a large percentage of U.S. hospitals have no isolation rooms. Only 61.7 percent of hospitals responding to the American Hospital Association 2004 annual survey reported having an airborne infection isolation room. 22 Airborne infection isolation rooms receive numerous air changes per hour (ACH) (>12 ACH for new construction as of 2001; >6 ACH for construction before 2001), and is under negative pressure, such that the direction of the air flow is from the outside adjacent space (e.g., the corridor) into the room. The air in an airborne infection isolation room is preferably exhausted to the outside, but may be recirculated provided that the return air is filtered through a high-efficiency particulate air (HEPA) filter. For more information, consult the HHS/CDC Guidelines for Environmental Infection Control in Health Care Facilities, available at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html. For care of pandemic influenza patients in the hospital: 4
Engineering Controls for Aerosol-Generating Procedures for Patients with Pandemic Influenza If possible, and when practical, use of an airborne isolation room may be considered when conducting aerosol-generating procedures, 4, 6 such as the following:
Cohorting If single rooms are not available, patients infected with the same organisms can be cohorted (share rooms). These rooms should be in a well-defined area that is clearly separated from other patient care areas used for uninfected patients. During a pandemic, other respiratory viruses (e.g., non-pandemic influenza, respiratory syncytial virus, parainfluenza virus) may be circulating concurrently in a community. Therefore, to prevent cross-transmission of respiratory viruses, whenever possible assign only patients with confirmed pandemic influenza to the same room. Management of cohort areas should incorporate the following: 4
Engineering Controls in Diagnostic and Research Laboratories During the Pandemic Alert Period, specimens from suspected cases of human infection with novel influenza viruses should be sent for testing to public health laboratories with proper biocontainment facilities. For example, reverse transcriptase polymerase chain reaction (RT-PCR) can be done in a Biosafety Level 2 laboratory but highly pathogenic avian influenza and highly pathogenic pandemic influenza virus isolation should be conducted in a Biosafety Level 3 laboratory with enhancements or higher as dictated by an appropriate risk assessment. Additional information on laboratory biocontainment is provided in the HHS publication Biosafety in Microbiological and Biomedical Laboratories. 25 Pneumatic tube systems are not advisable to transport specimens that may contain a highly pathogenic, live virus. Guidelines on when to send specimens or isolates of suspected novel avian or human strains to HHS/CDC for reference testing are available in Appendix 3 of the HHS Pandemic Influenza Planat http://www.hhs.gov/pandemicflu/plan/sup2.html#app3. 26 The American Society for Microbiology maintains a list of emergency contacts in state public health laboratories. 27 [Table of Contents] Autopsy Rooms for Cases of Pandemic Influenza Safety procedures for pandemic influenza-infected human bodies should be consistent with those used for any autopsy procedure with potentially infected remains. In general, the hazards of working in the autopsy room seem to depend more on contact with infected material, particularly with splashes on body surfaces, than to inhalation of infectious material. However, if the pandemic influenza-infected patient died during the infectious period, the lungs may still contain virus and additional respiratory protection is needed during procedures performed on the lungs or during procedures that generate small-particle aerosols (e.g., use of power saws and washing intestines). Protective autopsy settings for pandemic influenza-infected humans include the use of an airborne infection isolation room (see the section Airborne Infection Isolation Rooms on page 19). Exhaust systems around the autopsy table should direct air (and aerosols) away from healthcare workers performing the procedure (e.g., exhaust downward). It is important to use containment devices whenever possible (e.g., biosafety cabinets for the handling of smaller specimens). Therefore, an examiner conducting postmortem exams of pandemic influenza-infected patients will use airborne precautions, including a particulate respirator, as is recommended for postmortem exams of avian influenza-infected patients and SARS-infected patients. 28 [Table of Contents] Administrative Controls Respiratory Hygiene/Cough Etiquette Respiratory hygiene/cough etiquette, procedures should be used for all patients with respiratory symptoms (e.g., coughing and sneezing). The impact of covering coughs and sneezes and placing a mask on a coughing/sneezing patient on the containment of respiratory droplets and secretions or on the transmission of respiratory infections has not been quantified. However, any measure that limits the dispersion of respiratory droplets should reduce the opportunity for transmission. Masking some patients may be difficult, in which case the emphasis should be on cough etiquette. The elements of cough etiquette are listed below. For additional information, see Respiratory Hygiene/Cough Etiquette in Healthcare Settings at http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm. [Table of Contents] Pandemic Influenza Specimen Collection and Transport All human specimens of secretions and excretions should be regarded as potentially infectious. Healthcare workers who collect or transport clinical specimens should consistently adhere to recommended infection control precautions to minimize their exposure. Potentially infectious specimens should be placed in leakproof specimen bags for transport, labeled or color coded for transport and handled by personnel who are familiar with safe handling practices and spill clean-up procedures. Healthcare workers who collect specimens from pandemic-infected patients should also wear PPE as described for employees performing direct patient care. Specimens should be hand delivered where possible. Pneumatic tube systems are not advisable to transport specimens that may contain a highly pathogenic, live virus. For additional information about specimen collection, visit WHO's website at http://www.who.int/csr/disease/avian_influenza/guidelines/humanspecimens/en/index.html. [Table of Contents] Patient Transport within Healthcare Facilities Influenza-infected patients' respiratory secretions are the principle source of infectious material in healthcare settings. Maintaining source control of patient secretions will limit the opportunities for nosocomial (in hospital) transmission. The following methods of source control are consistent with those recommended for other serious respiratory infections (e.g., SARS, avian influenza, and tuberculosis. 4, 28, 29
Pre-Hospital Care and Patient Transport Outside Healthcare Facilities During an influenza pandemic, patients will still require emergency transport to a healthcare facility. The recommendations in the table on page 23 are designed to protect healthcare workers, including emergency medical services personnel, during pre-hospital care and transport. These recommendations can be instituted when patients are identified as having symptoms consistent with an influenza-like illness or routinely, regardless of symptoms, when pandemic influenza is in the community. [Table of Contents] Staff Education and Training It is incumbent upon healthcare employers to educate employees about the hazards to which they are exposed and to provide reasonable means by which to abate those hazards. The independent SARS Commission established by the government of Ontario noted that many healthcare staff were not adequately trained in protecting themselves against infectious agents. The Commission noted deficiencies in safety training and the proper use of personal protective equipment. 30 Effective staff training is consistent with facility policies and reinforces infection control strategies. Support from the healthcare institution at the top management and supervisory levels is essential for a successful program. Examples of educational goals and objectives for pandemic infection control strategies include:
Staff education and training should be available in formats accessible to individuals with disabilities and/or limited English proficiency; and should also target the educational level of the intended audience. [Table of Contents] Care of the Deceased Follow standard facility practices for care of the deceased. Practices should include standard precautions for contact with blood and body fluids. For more information regarding care of deceased, see Avian Influenza, Including Influenza A (H5N1), in Humans: WHO Interim Infection Control Guideline For Health Care Facilities, April 24, 2006, available at: http://www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1/en/. [Table of Contents] Patient Discharge If the patient is discharged while possibly still infectious, family members should be educated on hand hygiene, cough etiquette, the use of a surgical or procedure mask by a patient who is still coughing and any additional infection control measures identified in forthcoming guidance or recommendations. Updated guidance and recommendations will be posted on www.pandemicflu.gov whenever they become available. [Table of Contents] Visitor Policies Visitors should be strictly limited to those necessary for the patient's well-being and care, and should be advised about the possible risk of acquiring infection. Care of patients in isolation becomes a challenge when there are inadequate resources, or when the patient has poor hygienic habits, deliberately contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission of microorganisms (e.g., children, patients with an altered mental state, or elderly persons). Such patients should be managed on a case-by-case basis, balancing the rights of the patient with the risk they may present to others.
Healthcare Worker Vaccination An influenza pandemic occurs when a new version of an influenza virus develops the capability to infect humans and to spread easily and rapidly between people. Sometimes such new virus versions come from influenza viruses that previously affected only birds or animals, but which have mutated and thus have developed the capabilities to infect humans and spread easily among humans. It is believed that humans will initially have little, if any, immunity to a pandemic influenza virus and, therefore, that everyone will be susceptible to infection. The HHS Pandemic Influenza Plan assumes that one in five working adults will experience clinical disease in a pandemic influenza outbreak. 18 It also presumes that, in an affected community, a pandemic outbreak will last about 6 to 8 weeks with at least two pandemic disease waves likely to occur. Influenza vaccination is the most effective method currently available to prevent people from getting infected. During outbreaks of seasonal influenza, vaccination against that season's influenza subtypes usually prevents infection. If infection is not fully prevented, a vaccination may lessen the severity of the resulting illness. Once a new type of influenza virus emerges, it usually takes four to six months to produce a vaccine for that virus, using currently available vaccine production methods. There may be limited or no pandemic influenza vaccine available for administration to individuals in the first six months or longer during a pandemic. However, HHS plans to work with the pharmaceutical industry to produce and stockpile up to 20 million courses of vaccine against each circulating influenza virus with pandemic potential during the pre-pandemic period. 31 Stockpiled vaccine will be designated for personnel who perform critical and essential functions. Medical and public health employees who are involved in direct patient contact and other support services essential for direct patient care are likely to be given high priority for receipt of stockpiled vaccine. 32 Annual seasonal influenza immunization rates among healthcare workers in the United States remain low; coverage among healthcare workers in 2003 was 40.1 percent. 33 Therefore, to diminish absence due to illness, it is advisable for healthcare facilities to encourage and/or provide seasonal influenza vaccination for their staff, including volunteers, yearly, during the months of October and November. Vaccination strategy recommendations for health-care facilities in preparation for or in response to a pandemic influenza outbreak include: 34
Antiviral Medication for Prophylaxis and Treatment in Healthcare Workers The HHS Pandemic Influenza Plan assumes that oseltamivir will be the antiviral medication of choice in the event of an outbreak of pandemic influenza. 31 It assumes that supplies will be limited 31 and that the primary source of oseltamivir will be from federal stockpiles. Oseltamivir can be used to treat persons who are diagnosed with influenza; however, for optimal effectiveness, the treatment should be initiated within 48 hours of the onset of flu-like symptoms. Oseltamivir may also be used prophylactically to decrease the chance of infection in persons, such as healthcare workers, who have had exposure to pandemic influenza patients. Information on the advisability of using other antiviral medications during an influenza pandemic will be determined and communicated after the susceptibility of the causative viral subtype has been studied. Healthcare facilities should maintain contact with federal and local health departments concerning the availability of antiviral medications and the recommendations to administer antiviral medications as treatment or as prophylaxis to healthcare workers and emergency medical personnel who have direct patient contact. 34 Regardless of the availability of antiviral medication, it should not be used in lieu of a full infection control program.
Occupational Medicine Services Employee Protection Transmission in healthcare facilities was a major factor in the spread of SARS during the 2003 global epidemic. Factors that likely contributed to the disproportionate rate of transmission in healthcare settings included (1) exposure to infectious droplets and aerosols via use of ventilators, nebulizers, endotracheal intubation, and other procedures and (2) frequent and prolonged close contact of employees to patients, their secretions, and potentially contaminated environments. 35 Case recognition and implementation of appropriate precautions greatly reduced the risks of SARS transmission. However, even with appropriate precautions, there were isolated reports of transmission to healthcare workers in the settings of aerosol-producing procedures and lapses in infection control techniques. 29 Healthcare workers are also members of the community, and during seasonal influenza outbreaks their infectious illnesses may or may not be related to workplace infectious exposures. Seasonal vaccines will not protect against pandemic influenza, but will help prevent concurrent infection with seasonal influenza and pandemic influenza, which will minimize the possibility of reassortment of the virus. Protective levels of antibodies are usually detectable 2 to 4 weeks after vaccination with seasonal influenza vaccine. In addition, healthcare workers who provide direct patient care may be exposed to pandemic influenza viruses. These employees should be monitored for illness and supported as needed. [Table of Contents] Recommendations for Occupational Health Administrators Protecting healthcare workers benefits both the community and the individual employee. Comprehensive occupational health programs can limit transmission from infected employees and allow them to continue working while their services are in extreme demand. Surveillance Activities
Occupational Medical Surveillance and Staffing Decisions Occupational health played a major role in determining which healthcare workers should return to work during the SARS outbreaks. 19 In future outbreaks, individual risk assessment and fitness for duty determinations should be accomplished more efficiently with the support of updated staff medical records and with serologic testing results, if available.
Personal Protective Equipment Gloves HHS recommends the use of gloves made of latex, vinyl, nitrile, or other synthetic materials as appropriate, when there is contact with blood and other bodily fluids, including respiratory secretions.
[Table of Contents] Gowns 4
Goggles/Face Shields The HHS Pandemic Influenza Plan does not recommend the use of goggles or face shields for routine contact with patients with pandemic influenza; however, if sprays or splatters of infectious material are likely, it states that goggles or a face shield should be worn as recommended for standard precautions. 4 For additional information about eye protection for infection control, visit NIOSH's website at http://www.cdc.gov/niosh/topics/eye/eye-infectious.html. If a pandemic influenza patient is coughing, any healthcare worker who needs to be within 3 feet of the infected patient is likely to encounter sprays of infectious material. Eye and face protection should be used in this situation, as well as during the performance of aerosol-generating procedures. [Table of Contents] Respiratory Protection for Pandemic Influenza While droplet transmission is likely to be the major route of exposure for pandemic influenza, as is the case with seasonal influenza, it may not be the only route. Given the potential severity of health consequences (illness and death) associated with pandemic influenza, a comprehensive pandemic influenza preparedness plan should also address airborne transmission to ensure that healthcare workers are protected against all potential routes of exposure. Establishment of a comprehensive respiratory protection program with all of the elements specified in OSHA's Respiratory Protection standard (29 CFR 1910.134) is needed to achieve the highest levels of protection. Additional information on the Respiratory Protection standard is included in Appendix C in this document. More information on the elements of a comprehensive respiratory protection program and the use of respirators can be found at http://www.osha.gov/SLTC/respiratoryprotection/index.html. Healthcare workers are at risk of exposure to airborne infectious agents, including influenza. For some types of airborne infectious agents (such as SARS), healthcare workers are not only at risk for illness but may become a potential source of infection to patients and others. Selection of appropriate respiratory PPE requires an understanding of the airborne infectious agents, their infectious and aerodynamic properties, the operating characteristics of the PPE, and the behaviors and characteristics of the healthcare workers using the PPE. Many different types of respiratory PPE are available to protect healthcare workers, each with a different set of advantages and disadvantages. There will continue to be uncertainty about the modes of transmission until the actual pandemic influenza strain emerges. It is expected that there will be a worldwide shortage of respirators if and when a pandemic occurs. Employers and employees should not count on obtaining any additional protective equipment not already purchased and stockpiled. Therefore, it is important for healthcare facilities to consider respiratory protection for essential personnel to assure that employees are ready, willing, and able to care for the general population. Surgical Masks and Respirators Although some disposable respirators look similar to surgical masks, it is important that healthcare workers understand the significant functional difference between disposable respirators and surgical masks.
When personal protective equipment is necessary to protect against droplet transmission of infectious agents, employees must place a barrier between the source of the droplet (e.g., a sneeze) and their mucosal surfaces. Such protection could include a surgical mask to cover the mouth and nose and safety glasses to cover the eyes. Recent studies show that aerosol penetration through a surgical mask is highly dependent on particle size, mask construction, and breathing flow rate. One study showed that penetration rates for submicron particles could be as high as 80 percent for surgical masks. 36 Even relatively unconventional uses (e.g., the wearing of multiple surgical masks) have been shown to be less protective than NIOSH-certified respirators. For example, research has shown that the use of up to five surgical masks worn by volunteers results in particle reduction of only 63 percent for one mask, 74 percent for two masks, 78 percent for three masks, and 82 percent for five masks, compared with a recommended reduction of at least 95 percent for properly fitted N95 respirators. 37 To help employers and employees better understand respirators, the following paragraphs discuss their construction, classification, and use. Respirators A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer's risk of inhaling hazardous gases, vapors, or airborne particles (e.g., dust or droplet nuclei containing infectious agents). The many types of respirators available include:
A list of all NIOSH-certified disposable respirators is available at http://www.cdc.gov/niosh/npptl/respirators/disp_part/particlist.html. NIOSH also maintains a database of all NIOSH-certified respirators regardless of respirator type (the Certified Equipment List), which can be accessed at http://www.cdc.gov/niosh/celintro.html. Classifying Particulate Respirators and Particulate Filters An N95 respirator is one of nine types of particulate respirators. Particulate respirators are also known as "air-purifying respirators" because they protect by filtering particles out of the air as you breathe. Particulate respirators protect only against particles-not gases or vapors. Since airborne biological agents such as bacteria or viruses are particles, they can be filtered by particulate respirators. Respirator filters that remove at least 95 percent of airborne particles, during "worst case" testing using the "most-penetrating" size of particle, are given a 95 rating. Those that filter out at least 99 percent of the particles under the same conditions receive a 99 rating, and those that filter at least 99.97 percent (essentially 100 percent) receive a 100 rating. In addition, filters in this family are given a designation of N, R, or P to convey their ability to function in the presence of oils. "N" if they are Not resistant to oil. "R" if they are somewhat Resistant to oil. "P" if they are strongly resistant (i.e., oil Proof). This rating is important in work settings where oils may be present because some industrial oils can degrade the filter performance to the point that it does not filter adequately. (Note: This is generally not an issue in healthcare facilities.) Thus, the three filter efficiencies combined with the three oil designations leads to nine types of particulate respirator filter materials:
Recent HHS/CDC infection control guidance documents provide recommendations that healthcare workers protect themselves from diseases potentially spread through the air by wearing a fit tested respirator at least as protective as a NIOSH-certified N95 respirator. Employees can wear any of the particulate respirators for protection against diseases spread through the air, if they are NIOSH-certified and if they have been properly fit tested and maintained. As noted above, NIOSH-certified respirators are marked with the manufacturer's name, the part number, the protection provided by the filter, and "NIOSH." Employees who will be exposed to respiratory hazards other than airborne infectious agents (e.g., gases) should consult the NIOSH Respirator Selection Logic for more detailed guidance on appropriate respiratory protection at http://www.cdc.gov/niosh/docs/2005-100/default.html. Replacing Disposable Respirators Once worn in the presence of an infectious patient, the respirator should be considered potentially contaminated with infectious material, and touching the outside of the device should be avoided. Upon leaving the patient's room, the disposable respirator should be removed and discarded, followed by proper hand hygiene. If a sufficient supply of respirators is not available during a pandemic, healthcare facilities may consider reuse as long as the device has not been obviously soiled or damaged (e.g., creased or torn), and it retains its ability to function properly. Data on reuse of respirators for infectious diseases are not available. Reuse may increase the potential for contamination; however, this risk must be balanced against the need to provide respiratory protection for healthcare workers. Reuse of a disposable respirator should be limited to a single wearer (i.e., another wearer should not use the respirator). Consider labeling respirators with a user's name before use to prevent reuse by another individual. If disposable respirators need to be reused by an individual user after caring for infectious patients, employers should implement a procedure for safe reuse to prevent contamination through contact with infectious materials on the outside of the respirator. One way to address contamination of the respirator's exterior surface is to consider wearing a faceshield that does not interfere with the fit or seal over the respirator. Wearers should remove the barrier upon leaving the patient's room and perform hand hygiene. Face shields should be cleaned and disinfected. After removing the respirator, either hang it in a designated area or place it in a bag. Store the respirator in a manner that prevents its physical and functional integrity from being compromised. In addition, use care when placing a used respirator on the face to ensure proper fit for respiratory protection and to avoid unnecessary contact with infectious material that may be present on the outside of the mask. Perform hand hygiene after replacing the respirator on the face. Exhalation Valves Some filtering facepiece (and all elastomeric) respirators come equipped with an exhalation valve, which can reduce the physiologic burden on the user by reducing the resistance during exhalation. An exhalation valve may also increase the user's comfort by reducing excessive dampness and warmth in the mask from exhaled breath. The valve opens to release exhaled breath and closes during inhalation so that inhaled air comes through the filter. Healthcare workers may wear respirators with exhalation valves unless the patient has a medical condition (such as an open wound) for which a healthcare worker would normally wear a surgical mask to protect the patient. Similarly, respirators with exhalation valves should not be placed on a patient to contain droplets and prevent spread of infectious particles; surgical masks can be used for this purpose. Powered Air-Purifying Respirators Powered air-purifying respirators use HEPA filters, which are as efficient as P100 filters and will protect against airborne infectious agents. Powered air-purifying respirators provide a higher level of protection than disposable respirators. Healthcare facilities have used higher levels of respiratory protection, including powered air-purifying respirators, for persons present during aerosol-generating medical procedures, such as bronchoscopy, on patients with infectious pulmonary diseases. When powered air-purifying respirators are used, their reusable elements should be cleaned and disinfected after use and the filters replaced in accordance with the manufacturer's recommendations. All used filters should be considered potentially contaminated with infectious material and must be safely discarded. Powered air-purifying respirators may also increase the comfort for some users by reducing the physiologic burden associated with negative pressure respirators and providing a constant flow of air on the face. In addition, there is no need for fit testing of loose-fitting hood or helmet models. Special Considerations for Pandemic Preparedness If employers prepare appropriately, respiratory protection against pandemic influenza will be more effective. Establishment of a comprehensive respiratory protection program with all of the elements specified in OSHA's Respiratory Protection standard (29 CFR 1910.134) is needed to achieve the highest levels of protection. (See the section OSHA Standards of Special Importance on page 50 and Appendix C-1 of this document) Acquiring adequate supplies of appropriate respirators, ensuring that they fit key personnel, conducting appropriate training, and performing other aspects of respiratory protection can be accomplished in advance of a pandemic influenza outbreak. These measures should be repeated annually, prior to a pandemic being declared, to assure continued preparedness. If this is done, and the virus has an element of airborne transmission, the likelihood that employees will be effectively protected will be increased.
[Table of Contents] PPE for Aerosol-Generating Procedures During procedures that may generate increased small-particle aerosols of respiratory secretions, healthcare personnel should wear gloves, gowns, face/eye protection, and N95 respirators, surgical N95 respirators or other appropriate particulate respirators. Respirators must be used within the context of a respiratory protection program that includes a written program, fit testing, medical clearance, and training (see the section OSHA Standards of Special Importance and Appendix C-1for more information). Consider the use of an airborne isolation room when conducting aerosol-generating procedures, whenever possible. 4 Examples of procedures that generate aerosols include: 6
[Table of Contents] Order for Putting on and Removing PPE Based on the risk assessment, several items of PPE may be needed by healthcare workers when entering the room of a patient infected with known or suspected pandemic influenza. When PPE is necessary for the specific situation, HHS/CDC recommends that personal protective equipment be put on in the following order: 38
[Table of Contents] Work Practices Hand Hygiene To reduce the risk of becoming infected with influenza, healthcare workers working with influenza patients should follow rigorous hand hygiene measures. The HHS/CDC Guideline for Hand Hygiene in Healthcare Settings provides the recommendations for hand hygiene and the scientific support for the recommendations at http://www.cdc.gov/handhygiene. Basic hand hygiene recommendations that help protect healthcare workers working with influenza patients are: 3, 4
Other Hygienic Measures Healthcare workers working with pandemic influenza patients should also take care to: 4
Facility Hygiene-Practices and Polices When handling supplies and equipment contaminated with blood and other potentially infectious materials, employees must comply with OSHA's Bloodborne Pathogens standard. Dishes and Eating Utensils Standard precautions are recommended for handling dishes and eating utensils used by a patient with known or suspected pandemic influenza. 4
Linens and Laundry The following precautions are recommended for handling linens and laundry that might be contaminated with respiratory secretions from patients with pandemic influenza: 4
Patient Care Equipment To protect healthcare workers, standard practices for handling and reprocessing used patient care equipment, including medical devices, should be followed. 4
Environmental Cleaning and Disinfection Healthcare workers should use precautions when cleaning the rooms of pandemic influenza patients or of influenza patients who have been discharged or transferred. 4 Cleaning and Disinfection of Patient-Occupied Rooms
Standard precautions are recommended by HHS for disposal of solid waste (medical and non-medical) that might be contaminated with a pandemic influenza virus.
Laboratory Practices Follow standard facility and laboratory practices for the collection, handling, and processing of laboratory specimens. 4 Follow airborne precautions when engaging in aerosol-generating procedures for specimen collection, such as diagnostic sputum induction. [Table of Contents] References
Pandemic Influenza Preparedness An influenza pandemic is projected to have a worldwide impact on morbidity and mortality, thus requiring a sustained, large-scale response that has the potential to quickly overwhelm hospitals and the healthcare system regionally and nationally. Because an influenza pandemic may quickly overwhelm the healthcare community (hospitals, outpatient clinics, the pre-hospital environment, nursing homes, assisted living centers, and private home healthcare) planning should address: (1) internal continuation of care and (2) coordination of services with local, state, and federal healthcare agencies. Healthcare resources are not easily shared or redistributed; a pandemic will magnify and strain resources on a much larger scale. Collaboration with state and federal partners is vital to ensure that healthcare facilities have assistance with consumables, medication, and vaccines during the pandemic. 1, 2, 3 This section addresses pandemic planning issues affecting healthcare personnel, the most valuable resource in a pandemic crisis. 1, 2, 3 It is beyond the scope of this document to give specific details on resource management for individual healthcare settings. Instead, comprehensive planning for these issues, such as surge capacity, facility space management, and consumable and durable equipment utilization should be developed in coordination with local, state, and federal agencies. There are several checklists, toolkits, and guidelines that will assist healthcare providers and service organizations in planning for a pandemic outbreak available at http://www.pandemicflu.gov/plan/healthcare/index.html. For additional influenza pandemic planning resources, see the Appendix section of this document. [Table of Contents] Healthcare Facility Responsibilities During Pandemic Alert Periods In the event of a pandemic, HHS/CDC will coordinate support and intelligence with U.S. public health departments regarding the pandemic situation in the U.S. and in foreign countries. The Homeland Security Council (HSC) National Strategy for Pandemic Influenza Implementation Plan has identified stages for federal government actions during a pandemic. The stages are based on spread of the virus in other countries and in the United States. These stages can be incorporated into healthcare pandemic planning to identify triggers for implementation of different aspects of the facility plan. Below is a broad outline of pandemic planning for healthcare facilities based on stages of the Homeland Security Council National Strategy for Pandemic Influenza Implementation Plan and the HHS Pandemic Influenza Plan recommendations. 1, 4 [Table of Contents] Healthcare Facility Responsibilities Before a Pandemic (HSC Stages 0, 1)
Healthcare Facility Responsibilities During the Pandemic (HSC Stages 2 – 5) If there are confirmed human outbreaks overseas (Stages 2 – 3):
Healthcare Facility Recovery and Preparation for Subsequent Pandemic Waves (HSC Stage 6)
Incorporating Pandemic Plans into Disaster Plans Hospitals already address emergency management plans as part of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. Standards EC.4.10 and EC4.20 address emergency management and require hospitals to conduct a hazard vulnerability analysis as a first step in disaster planning. A hazard vulnerability analysis allows hospitals to assess the type, probability, impact, and severity of specific hazards and disasters. This information allows hospitals to anticipate the effects of these events and facilitates customized planning and resource stockpiling. Specific information on conducting a hazard vulnerability analysis can be obtained though the Joint Commission Resources, an affiliate of JCAHO. 5, 6 In 2003, the National Hospital Ambulatory Medical Care Survey reported that about 97 percent of surveyed hospitals had plans for responding to natural disasters and 85 percent had plans to respond to bioterrorism events. Although 75.9 percent reported cooperative planning with other facilities, only 46.1 percent had written Memoranda of Understanding regarding acceptance of patients during a disaster. The survey revealed that hospitals drilled for natural disasters more than for terrorism events and drilled even less for severe epidemics. 7 Despite recommendations and requirements for disaster planning, some institutions may be unprepared for a pandemic event. To address this concern, healthcare institutions should consider incorporating pandemic influenza planning into disaster planning by developing an algorithm that would group biologic agents with similar characteristics (i.e., smallpox, plague, influenza, severe acute respiratory syndrome (SARS)). 3 Plans should address some key differences in biological disaster plans and influenza pandemic plans. [Table of Contents] Pandemic Planning for Support of Healthcare Worker Staff Although a pandemic will be a nationwide event, it will be experienced on a local level. An important difference between pandemic planning and mass casualty planning is the understanding that during an influenza pandemic, hospital staff will be a limited resource, without an opportunity for replenishment from other communities. Plans must address protection of this vital and critical resource. Planning assumptions in the National Strategy for Pandemic Influenza Implementation Plan include a 30 percent attack rate in the U.S. population, 50 percent of those ill will seek medical attention, and an absenteeism rate of up to 40 percent. For information regarding planning assumptions, see http://www.pandemicflu.gov/plan/pandplan.html. These assumptions could also be adapted for local pandemic planning purposes to address hospital staffing shortages and surge requirements. 1 [Table of Contents] Define Essential Staff and Hospital Services Defining essential staff and services is typically one of the first and most vital steps in pandemic planning. During a pandemic, non-pandemic hospital services such as trauma care, obstetrics, cardiac care, and psychiatry will still need to be provided or a referral service made available. Hospitals need to identify crucial administrative staff, food services staff, housekeeping, security, and facilities staff. Once these essential personnel and positions are identified, consider implementing cross-training to ensure that these processes will continue. Also, identify and develop methods and policies in compliance with federal, state and local requirements for keeping nonessential staff out of the facility such as through reassignment, administrative leave or furlough policies. However, even if an individual's position is considered nonessential, these personnel may be cross-trained and utilized as a contingency workforce. 3, 4, 8, 9, 10 Physicians and nurses with crucial knowledge of infectious disease, pulmonary medicine and critical care medicine will need to be identified. Nurses are currently an understaffed profession; in a pandemic situation, this shortage will be even more pronounced. Consider how to maximize nursing care by estimating the number of staff needed to care for a single patient or multiple patients, and then plan how to meet those needs when there is an increase in patients or a decrease in staff. Medical and nursing students may be a potential resource to meet staffing shortages and to extend care. The HHS Pandemic Influenza Plan advises that patients' family members could be used in an ancillary healthcare capacity. Identify other critical care personnel such as respiratory therapists, pharmacists, laboratory employees, blood bank and morgue staff. To prepare for staffing shortages, consider cross-training staff for essential areas such as the emergency department or intensive care units. 4, 8, 9, 10 [Table of Contents] Human Resources Hospital staff and healthcare workers will be a limited resource during a pandemic influenza outbreak due to illness and/or absenteeism. There will be a need for people with healthcare training, of any level, to meet the increased demands on the local healthcare community. Begin working with other facilities and clinics to develop Memorandums of Understanding for staffing support. Work with these medical clinics to ensure that healthcare workers in the community are aware of institution planning, protocols and training. Provide communication infrastructure to ensure that practitioners in the community have the resources to integrate with larger facilities. 1, 4, 8 Healthcare employers should be prepared to support existing employees and to accommodate an influx of new providers, both volunteers and recruited individuals. Healthcare facilities should work with JCAHO and state medical boards to ensure an expedited but legal credentialing process. A potential resource for personnel augmentation is state Emergency Systems for Advance Registration of Health Professions Volunteers (ESAR-VHP). These state systems are being developed in partnership with HHS to register, classify and verify credentials of potential health professional volunteers in each state (http://www.hrsa.gov/esarvhp/) Local Medical Reserve Corps units may also be sources of volunteer health professional personnel in the immediate vicinity of a facility (http://www.medicalreservecorps.gov/HomePage). 1, 4 Pandemic influenza planners should also address workers' compensation issues in advance, including workplace injuries and illness to volunteers and new recruits working in response to a pandemic. Experience during the SARS outbreak showed that wages and salary issues may also arise as health-care workers are requested to work with infectious cases. 8, 9 Workplace issues arising in the context of a pandemic (e.g., reassignment, payment of wages or salaries, voluntary or involuntary sick leave, delegation of work duties) should be resolved in compliance with federal, state, and local laws, including equal employment opportunity laws. Human resources should be involved in planning for other employee support concerns such as the possible need for housing, meals, places to rest, and child care services. Prepare and plan how the healthcare facility will provide these services in planning stages so that during a crisis, employees will already have this information. 11 [Table of Contents] Information Technology During a pandemic situation, communication capabilities to provide risk communications internal and external to facilities are essential. Adequate communication infrastructure (computers, Internet, and radios) will ensure that providers, patients and community resources can exchange accurate, timely information about the situation. Equipment should be tested to ensure compatibility with emergency services, law enforcement, security and public health. Inability to communicate effectively because of technology incompatibility could result in further strain on the healthcare system and healthcare workers. 12, 13, 14 It is anticipated that during an influenza pandemic the members of the healthcare community will increase their reliance on information technologies. Quarantine requirements during the SARS outbreak made it difficult for hospital staff to receive current information about the outbreak situation, particularly changing treatment strategies, and recommendations for personal protective measures. The cancellation of medical rounds and business meetings further exacerbated the lack of personal communications. E-mail, telephone conferences, and Internet access enabled healthcare providers to access treatment specialists external to the facility, and obtain the information required to maintain the most current standards of care from public health experts. Once these processes were in place, healthcare providers were able to address effective patient treatment and personal protective measures. Pandemic planning should address the anticipated increased reliance on information technologies and ensure that the communication infrastructure enables healthcare workers to access the most current recommendations. 4, 8, 9, 10, 12, 13, 14, 15 [Table of Contents] Public Health Communications Healthcare facilities need to develop strong risk communications resources as part of pandemic planning for both the community that they serve and their employees. Risk communications should be available in formats accessible to individuals with disabilities and/or limited English proficiency, and should also target the educational level of the intended audience. Communication with the community, including public relations and risk communications, will be required to ensure that the general public is educated in self-care techniques, social distancing and access to the appropriate level of care. 15 Healthcare facilities and outpatient clinics should consider telephone hotlines and websites to provide health advice to the public. Hotlines and websites can educate the public in self-care or direct ill individuals to the appropriate level of care and decrease the burden on healthcare facilities. Healthcare facilities and clinics can also institute follow-up phone or e-mail communication to ensure that discharged or home-care patients are adequately managed. 1, 4, 15 HHS has developed resources for avian influenza and pandemic influenza communications using the communication science-based message mapping development process. "Message maps" are risk communications tools used to help organize complex information and make it easier to express current knowledge. The development process distills information into easily understood messages written at a sixth grade reading level. These pandemic influenza and avian influenza message maps may be copied and redistributed on paper or electronically (http://www.pandemicflu.gov/rcommunication/pre_event_maps.pdf). During a pandemic there will be rumors and misinformation that can impact healthcare staff and the community. Fraudulent information about counterfeit vaccines and antiviral medications may be circulated via multiple communication sources. 1, 16 Malicious misinformation may also be launched against local, state and federal agencies. 16 Without a reliable means to communicate accurate information, misinformation may adversely impact health-care facilities and the public health infrastructure. For additional information regarding public health communications see:
[Table of Contents] Surveillance and Protocols Surveillance is a cornerstone of disaster preparedness. Healthcare facilities and outpatient clinics both need to address and implement the capacity to identify and track influenza-like illness. This capability includes identifying appropriate laboratory capacity, the ability to conduct epidemiology on influenza-like illness and to report collected data to the appropriate state and federal agencies. Once a surveillance program is established, healthcare facilities will be able to identify the onset of a severe influenza season, identify biologic weapons (anthrax, plague, etc.) and monitor for pandemic influenza and/or other emerging respiratory infections (i.e., SARS, Hantavirus pulmonary syndrome). Healthcare facilities should conduct internal surveillance to monitor for nosocomial transmission of influenza to staff and other patients. Internal surveillance for nosocomial transmission could be used to identify inadequate infection control practices/procedures . 1, 12, 17, 18, 19 Effective disease surveillance depends on cooperation with local, state, and federal health agencies to ensure that healthcare facilities have access to influenza diagnostic criteria, confirmatory laboratory tests, and an understanding of the reporting process in the event of an influenza pandemic. Health departments in all fifty states and Chicago, New York City and Washington, D.C. have dedicated influenza surveillance coordinators who promote year-round influenza surveillance. These are important resources for both hospitals and clinics. In the outpatient setting, the Sentinel Provider Network (SPN) is a network of healthcare providers who report the number of weekly influenza-like illness visits and submit samples for testing. State public health departments can assist outpatient providers who wish to participate in the surveillance program. Healthcare facilities can participate in the Emerging Infections Program (EIP) and New Vaccine Surveillance Network (NVSN). Like the SPN, the EIP and NVSN are administered through state health departments and coordinated with federal agencies such as HHS/CDC. Information about participation in these surveillance activities is coordinated through state health departments. 1, 17 Healthcare organizations, hospitals and outpatient clinics at least should develop a process to monitor the following federal and global sources to obtain the latest information on seasonal influenza, avian influenza, pandemic influenza, and other novel respiratory illnesses:
Facilities should also develop visitor screening and access policies for a pandemic. If these policies are not developed in advance, visitor access becomes a security issue and a source of stress for staff, patients, and families. Visitor policies should address access to ill family members, particularly pediatric patients, and policies for visitation of deceased patients. 21 Visitation policies will be easier for the public to accept if the justification and rationale are explained before a crisis. 4, 21 [Table of Contents] Psychological Support Psychological and behavioral health support for hospital staff is a recommended part of pandemic planning. 11, 20, 22, 23, 24 Personnel will be exposed to public education and outreach with the potential for conflicting messages, public health surveillance efforts, and community containment strategies in addition to work-related efforts involving mass prophylaxis strategies, ethical dilemmas due to shortages of critical supplies and surges in demand for healthcare service, and possible work-related stigma or maladaptive responses of coworkers due to changes in work practices or loads. Pandemic planning should address numerous areas of potential distress, health risk behaviors, and psychiatric disease amongst healthcare system personnel. The importance of psychological support for healthcare staff was illustrated during the SARS outbreak in Canada. During the initial outbreak in Toronto, there was a high perception of risk due to lack of information about infection control, morbidity and mortality. 8, 13, 14, 20, 25 Healthcare workers, particularly those working directly with SARS patients, reported feeling afraid, helpless, angry, guilty, and frustrated. One of study of nurses who treated SARS patients in Taiwan demonstrated an 11 percent rate of traumatic stress reactions, including depression, anxiety, hostility, and somatization symptoms. 26 However, despite the risk, healthcare workers in Toronto and Asia continued to report to work. 8, 13, 20 The psychological impact of SARS was not only felt among personnel directly involved in caring for SARS patients, but also among hospital employees who were restricted from work either because they were not in essential positions or quarantined due to exposure or illness. Supervisors and employees reported feeling isolated and ineffective, and expressed relief when reassigned to duties in the facility. Reintegrating employees back into work was also difficult. Employees reported feeling disorganized and disconnected and reported some resentment between employees who had been required to work and those who had been removed. 11, 20 The impact of treating SARS cases was not isolated to the workplace. In order to protect their families, healthcare workers often isolated themselves at home. Healthcare workers and their families reported experiencing ostracism outside the workplace and stated that people in the community were afraid to associate with them and their families. 8, 11 Healthcare facilities should plan and implement psychological resources for hospital staff during and after a pandemic. If there are adequate resources, facilities should consider extending services to employee family members. 11 The following resources provide detailed recommendations for incorporating psychological support for healthcare workers and their families into pandemic planning:
[Table of Contents] Occupational Health Services Identifying and collaborating with institutional occupational health services is vital to effective pandemic influenza planning. Occupational health services can coordinate and participate in a variety of pandemic influenza preparedness and response activities. [Table of Contents] Developing and Providing Employee Screening for Influenza-Like Illness Occupational health services can monitor employee absentee rates in both the pre-pandemic planning stages and during a pandemic in order to gauge the impact and progression of the pandemic on the facility and the community. In the event of an influenza pandemic, all staff should be screened for illness before contact with patients or other health-care workers. Planning should include processes to screen employees, track ill healthcare staff and reintegrate staff back into the workplace after recovery. 4, 9, 27 A sample screening form is available from the WHO document Influenza A (H5N1): WHO Interim Infection Control Guidelines for Healthcare Facilities, Annex 10 at http://www.who.int/csr/disease/avian_influenza/guidelinestopics/en/index3.html. The form screens employees for signs and symptoms of infection over multiple days, providing a mechanism to ensure that exposed individuals are symptom-free before contact with patients and staff. [Table of Contents] Developing and Providing Immunization and Treatment Strategies Occupational health services should be prepared to work with state and federal agencies in order to facilitate pandemic influenza vaccination for employees and the public. Healthcare facilities and organizations need be aware of and coordinate with state pandemic planners to assure access to available vaccine. 1, 4 The pandemic vaccine may require multiple doses, so occupational health services should develop a system to identify and record vaccination status for pandemic vaccine recipients. In addition to a pandemic influenza vaccine planning strategy, a current, aggressive vaccination program against seasonal influenza is integral to institutional preparedness. An effective seasonal influenza program can be adapted for a pandemic vaccination campaign. 4 Antiviral medication may be a treatment option for ill healthcare staff. To maximize effectiveness, these medications should be given as soon as possible within 48 hours of the onset of symptoms. Screening for appropriate, early treatment of influenza cases among healthcare workers and essential staff could decrease the duration and severity of staffing illness and absence. Occupational health services should also be prepared to treat secondary bacterial infections in healthcare workers. Treatment and prophylaxis recommendations will be determined by HHS, but planning for employee screening and treatment should be implemented during the pandemic process. 4, 27 [Table of Contents] Continuing Baseline Occupational Health Services During an influenza pandemic, protection against existing occupational hazards (e.g., bloodborne pathogens and tuberculosis) will need to continue. Pandemic influenza planning should include a process to quickly integrate volunteers and recruited staff into healthcare facilities to ensure that healthcare workers are adequately protected. Despite the demands of a pandemic, infection control practices will still need to be maintained. Bloodborne pathogens exposure control plans, respiratory protection programs, and tuberculosis screening must be continued during an influenza pandemic. New staff and volunteers should be included in these programs to ensure facility and employee safety and health. [Table of Contents] Training Training for a pandemic is essential to ensure continued effective operation of the facility. Cross-training and volunteer training for essential functions should be initiated early in pandemic preparedness planning. If advance training is not an option, then ensure that protocols and resources for just-in-time training are in place. If possible, identify pools of back-up staff or volunteer staff and began training these individuals in infection control practices and respiratory protection (including fit testing) to ensure smooth integration in the healthcare facility in the event of a pandemic. It is important to remember that patient care providers are not the only personnel that need pandemic preparedness training. For example, food services, housekeeping, information technologists, facility managers and human resources are critical functions and may require pandemic-specific training (i.e., hygiene practices). 4, 9 Healthcare facilities should also consider developing training for families of employees. Ensuring that families of healthcare workers are educated about hygiene and disease can protect healthcare systems and reduce employee absence. 11 JCAHO requirements include training and drills as part of disaster planning. Drilling for a pandemic situation ensures that facilities are prepared for surge capacity, supply chains, communication infrastructure, and adequate occupational safety and health protocols. Disaster drills allow planners to identify hidden complications that may arise in the event of a pandemic. 5, 6 [Table of Contents] Security A pandemic crisis will intensify the need for facility security. Security will be an essential function and additional personnel may be needed during a pandemic.1, 2, 4 A pandemic will require facilities to limit access and implement isolation measures to sepa-rate potential cases from staff, visitors, and other patients. In a pandemic, healthcare facility security may need to be ready to address crowd control and physical protection of the facility and hospital staff.4 Security staff will be interfacing with a scared and potentially dangerous public. Not only will security personnel be at risk for infection, but they may have to confront violent individuals demanding resources and healthcare. Training and providing personal protective equipment (PPE) is essential for these hospital personnel. Facilities should incorporate training and support for security personnel in the pandemic planning process. Healthcare facilities should also work with local and federal law enforcement agencies to address facility security. Consider preparing security plans with local and state law enforcement. This will allow law enforcement agencies to develop procedures for entrance to and egress of from the facility, public access issues, and protection of critical supplies. Ensure that law enforcement understands facility structure and layout in advance of a crisis. Identify key individuals to liaison with law enforcement agencies and coordinate planning and communications (i.e., radios). Without adequate security and the cooperation of law enforcement agencies, healthcare facilities may not be able to function during a crisis. [Table of Contents] Stockpiles of Essential Resources An issue that all healthcare facilities must address as part of pandemic planning is stockpiling resources. Due to logistic and economic concerns, this element of disaster planning is often neglected. In 2004, the state of Kentucky conducted a survey of mass casualty planning in healthcare facilities. Thirty-eight percent of respondents had emergency plans that addressed stockpiling antibiotics and supplies and only 25 percent of hospitals actually had a separate cache of antibiotics for staff in the event of a bioterrorist event.28 Influenza pandemic planning adds additional challenges for disaster stockpiling. An influenza pandemic will be sustained and widespread, and pharmaceutical interventions are currently in short supply or nonexistent. These factors limit the ability of facilities to stockpile pandemic resources. For this reason, healthcare facilities should ensure that pandemic plans address the ability to access local, state and federal stockpiles. Integration with these resources is vital to ensure distribution and rotation of essential supplies during a crisis.1, 3, 4, 29 HHS has recommended that healthcare facilities consider developing institutional stockpiles of resources to counter supply shortages and transportation issues that may impact the ability to access federal and state supplies.4 JCAHO disaster guidance recommends that hospitals have a 48-to72 hour stand-alone capability;30 however, an influenza pandemic may surge through a community for 6 to 8 weeks. Consequently, stockpile planning will have to balance economic and logistical demands with the duration of pandemic waves and healthcare supplies. Because of resource shortages and economic concerns, healthcare facilities could further optimize assets by developing coordinated stockpiles with other local facilities.1 HHS/CDC has medical supplies and medications stored in the Strategic National Stockpile (SNS) (http://www.bt.cdc.gov/stockpile). Pandemic and disaster planning should include working with state and federal resources to address access to this supply. [Table of Contents] Pandemic Influenza Vaccine In the event of a pandemic, it is currently estimated that production of initial doses of a vaccine against a novel strain of influenza would take approximately 4 to 6 months. Influenza vaccines are typically grown in fertilized chicken eggs, a process that takes several months. Federal funding has been made available for the development of cell-based vaccine technologies that have the potential to expedite the production of a novel influenza vaccine. In May 2006, HHS awarded contracts totaling more than $1 billion for development of cell-based vaccine technologies.1, 31, 32 Pandemic planning should include protocol development and the stockpiling of supplies for administering pandemic influenza vaccine. Distribution and vaccination recommendations will be coordinated through state and local public health departments. It is critical that healthcare services coordinate with these agencies in order to obtain and administer pandemic vaccine.1, 32 HHS will determine pandemic vaccine recommendations and prioritization groups (e.g., number of doses recommended, indications, contraindications and ranking of various groups for priority for immunization). Current recommendations regarding pandemic influenza vaccine are available in Part I. Appendix D and in Part II. Supplement 6 of the HHS Pandemic Influenza Plan at http://www.hhs.gov/pandemicflu/plan/appendixd.html and http://www.hhs.gov/pandemicflu/plan/sup6.html. Prioritization, based on HHS recommendations, may change. Planning activities should include a process for obtaining and integrating up-to-date pandemic vaccination recommendations. A vaccine against a pandemic influenza strain may require two doses to provide adequate immunity, therefore, pandemic planning should include developing a procedure to register, track and contact individuals who have received immunizations.18, 32, 33 Research is currently being conducted into the development of more immunogenic vaccines. Vaccines which contain chemical additives called adjuvants can increase the immune response and require the use of less viral protein which could extend the vaccine supply. Research into other methods of developing vaccines or vaccine delivery systems is ongoing, but as of October 2006, none have received an FDA license.18, 32, 33 An important part of pandemic planning is institution of an effective, seasonal influenza campaign which includes encouraging healthcare workers to get vaccinated for seasonal influenza. Unfortunately, current rates of healthcare worker influenza vaccination are not encouraging; only about 40 percent of healthcare workers were vaccinated in 2003.34 [Table of Contents] Antiviral Medication In contrast to the vaccine, antiviral medications for the treatment of influenza do not need to be specific to the circulating pandemic strain and, thus, are more amenable to stockpiling. There are two classes of antiviral drugs that are U.S. Food and Drug Administration-approved for the treatment of influenza: the neuraminidase inhibitors (oseltamivir and zanamivir) and the M2 inhibitors (adamantine and rimantadine). Unfortunately, influenza A viruses can develop resistance to either class of antiviral drug, and especially rapid emergence of transmissible resistant virus has been reported after treatment with adamantanes.33, 35, 36 Although hospitals are encouraged to stockpile these drugs, it is impossible to predict which medication will appropriately treat the pandemic virus or if the pandemic virus will develop resistance to one or both classes of medications. Resistance to amantadine and rimantadine has already occurred in the H3N2 seasonal influenza A viruses. As of July 2006, the HHS recommendation for treatment of H5N1 avian and seasonal influenza is to use the medication oseltamivir.35, 36 Because of worldwide demand, healthcare facilities may have difficulty stockpiling this medication. The federal government is building a national stockpile with a long-term plan to acquire enough antiviral medications to treat approximately 25 percent of the U.S. population. As of March 2006, there were approximately 5.5 million treatment regimens of antiviral medication in the SNS and approximately 14 million more were on order. The SNS contains both classes of antiviral drugs, but the largest stockpiled medication will be the neuraminidase inhibitor oseltamivir. The targeted SNS level is 50 million courses by 2008. The federal government also plans to subsidize the states' purchase of an additional 31 million courses.29 State allocations from the national stockpile can be found at http://www.pandemicflu.gov/plan/states/antivirals.html. The decision to deploy federal assets from the SNS will be made by HHS officials. Each state and federal agency will need a designated representative to make emergency requests and coordinate with HHS to access SNS resources. These representatives will provide logistic guidance on receipt and distribution of the requested assets. Healthcare facilities should integrate and communicate with state planners or there could be difficulty accessing critical medications.1, 37 Healthcare plans should be developed for the allocation of antiviral medication with the assumption of limited supplies. Strategies for treatment will be outlined by HHS. Recommendations for use of antivirals may be updated throughout the course of an influenza pandemic based on epidemiologic and laboratory data. Pandemic influenza plans should incorporate the ability to update and adapt to the latest HHS guidance. Planning must include methods to screen patients and employees and to ensure that these medications are administered in a fair manner consistent with HHS recommendations.37, 38, 39 A local plan for distribution, point-of-care locations and establishment of priority groups is crucial. Because of the resource limitations and time constraints for efficacy of the medication, developing plans and infrastructure to access, deliver, and prioritize use of this medication must be done in advance. As with vaccinations, this process should be transparent and healthcare facilities should develop a risk communication plan that will keep both healthcare workers and the community updated on current treatment recommendations.37, 38, 39 Stockpiles of antiviral medication may be a security issue if there is large pandemic. Consider not only working with hospital security, but also with local and state law enforcement officials to ensure adequate security during a crisis. Healthcare facilities should also consider stockpiling additional medications to treat secondary infections and pneumonia. Antibiotics and pulmonary medications such as inhalers and nebulizers are stockpile options for treatment and care. Hospitals should arrange for occupational or employee health clinics to develop distribution plans that address employee illness and exposure. These plans need to be flexible to accommodate HHS guidance for distribution and prioritization when a pandemic virus emerges. Once developed, the policy for using stockpiled supplies and administration of antiviral medications should be transparent to employees and the community, including the rationale and justification for the policies. 2005 HHS recommendations for antiviral medical priority groups can be located in Appendix D of the HHS Pandemic Influenza Plan at http://www. hhs.gov/pandemicflu/plan/sup7.html. Personal Protective Equipment Given that pandemic influenza vaccine will likely not be available until 4 to 6 months into the pandemic and that shortages of antiviral medications are anticipated, PPE will be especially important for protecting healthcare workers. However, logistic and economic considerations may impact the ability for healthcare facilities to stockpile PPE. For example, the SARS outbreak in Toronto lasted approximately 6-7 months. One large hospital reported that at the height of the epidemic the daily consumption of PPE equipment included 3,000 disposable gowns, 14,000 pairs of gloves, 18,000 N95 respirators, 9,500 ear loop masks, and 500 pairs of goggles. In the first week of the SARS outbreak, the hospital purchased $1 million worth of supplies, although their annual hospital budget was only $50 million per year. 9, 40 There were 438 confirmed or suspected SARS cases in Canada. 8 In total, it is estimated that the cost to Ontario province's healthcare system for the SARS outbreak in Toronto was approximately $763 million. 40, 41 The impact of pandemic influenza would be much greater than the impact of SARS. HHS/CDC modeled a pandemic influenza crisis in the metro Atlanta area with a 25 percent gross attack rate. The model estimated that there would be 412 hospital admissions a day, with a total of 2,013 cases hospitalized in one week during the peak of the outbreak. 42 This is about 4.5 times the number of patients hospitalized during the Toronto SARS outbreak. Although only a model, this example illustrates how complicated the issue of stockpiles and resources will be during a pandemic. Storage of a large supply of PPE may be difficult and costly. Some hospitals are working with distributors to have a stockpile maintained at distributor sites. If there is careful planning for access, transport and delivery of the required PPE, this could be an acceptable option. 4 HHS suggests stockpiling the following PPE resources: 4
[Table of Contents] Outpatient Services and Clinics HHS/CDC estimates that in a pandemic, approximately 45 million people with pandemic influenza will seek outpatient medical care in the United States (http://www.pandemicflu.gov/plan/pandplan. html). Outpatient clinics should prepare for a surge in utilization of services for pandemic-related illness while continuing to provide medical services for treatment of other acute and chronic medical conditions. Clinics and urgent care centers must identify which services can be curtailed in a pandemic and which services will need to expand. Optimally, clinics should coordinate planning efforts with local hospitals, healthcare organizations and public health agencies. Outpatient clinics could serve as resources to augment healthcare facilities or alternatively, be utilized to reduce the impact on hospitals by treating and addressing care for pandemic patients not requiring hospitalization. Clinics should identify essential personnel and services, identify critical supplies and prepare for expanded services. 4 Further guidance and information can be found at http://www.pandemicflu.gov/plan/medical.html. Outpatient service providers should prepare for staffing shortages and develop contingency operations plans. Additionally, protocols for triage and education of patients should be developed. In preparing for an influenza pandemic, HHS recommends that clinics stockpile at least one week of consumable supplies, including PPE, when there is evidence that a pandemic has begun in the United States. Performing triage, ensuring social distancing and isolation of potentially infectious patients will be a challenge in the outpatient care community. Pandemic phone hotlines and websites can be an option to provide education and self-care for clinic patients in order to avoid unnecessary clinic visits. Isolation of potentially ill patients could be difficult; clinics will need protocols and procedures to maintain appropriate distancing and provide education to patients on infection control. 43 In addition to providing care for patients, clinics have the responsibility for ensuring that employees and healthcare workers are adequately protected during an influenza pandemic. Many of these recommendations in this document can be tailored to the outpatient setting, including these use of appropriate PPE. Clinics may need to develop respiratory protection programs and develop appropriate infection control training for employees. Integration with other clinics and healthcare facilities and public health agencies may assist clinics in this process. [Table of Contents] Alternate Care Sites Alternate care sites may be developed at federal or state discretion to ease the burden of care on healthcare facilities. Some alternate care sites may support the community by providing triage and teaching self-care to individuals who are not critically ill. Vaccination and medication distribution centers may also be opened depending on the availability of these resources. 1, 4 The use and deployment of these facilities will vary, but the requirement to provide a safe workplace does not diminish. It is important that local and state plans address these alternate sites and determine adequate training and PPE for employees assigned to these facilities. Respiratory protection programs and infection control programs will need to be developed and implemented before the facilities are opened to the public. Healthcare facilities should consider how they can facilitate the provision of training and safety resources to the community before a pandemic situation arises. Primary care providers who have clinics in the community will need to be trained in the use of PPE and infection control practices. HHS has developed a checklist to help clinics develop pandemic disaster plans (http://www.pandemicflu.gov/plan/medical.html). 4 Local and state pandemic planning should include outreach programs to provide necessary training to these healthcare workers. JCAHO has guidance for the development of surge hospitals at http://www.jointcommission.org/PublicPolicy/surge_hospitals.htm. [Table of Contents] References
OSHA Standards of Special Importance The role of OSHA is "to assure safe and healthful working conditions for working men and women." 1 Employers have a responsibility to furnish employees "a place of employment which is free from recognized hazards that are causing or are likely to cause death or serious physical harm." 1 In addition, employers must comply with occupational safety and health standards promulgated by OSHA or by a state with an OSHA-approved state plan. (More information about state occupational safety and health programs can be found at http://www.osha.gov/fso/osp/index.html.) OSHA standards applicable to healthcare facilities are addressed in the standards for General Industry. In addition, the Respiratory Protection standard, the Personal Protective Equipment standard, and the Bloodborne Pathogens standard have special importance to pandemic preparedness and response. [Table of Contents] Respiratory Protection Standard - 29 CFR 1910.134 The primary objective of OSHA's Respiratory Protection standard is to protect employees against inhalation of harmful airborne substances or oxygen-deficient air. This standard applies to all occupational airborne exposures where employees are exposed to a hazardous level of an airborne contaminant. The inhalation of pathogenic organisms known to cause human disease is covered by this standard. Employers are required to use feasible engineering controls as the primary means of controlling air contaminants. Respirators should be used for protection only when engineering controls have been shown to be technologically or economically infeasible or while they are being instituted for the control of the hazard. Healthcare facilities requiring the use of respirators must implement a comprehensive respiratory protection program. These programs are to be overseen by a qualified program administrator and have key elements that include respirator selection, training, medical certification, fit testing, maintenance and cleaning, and program review. Additional information on the Respiratory Protection standard is included in Appendix C in this document. Information describing all of the elements of a comprehensive respiratory protection program and the use of respirators can be found at http://www.osha.gov/SLTC/respiratoryprotection/index.html. [Table of Contents] Personal Protective Equipment Standard 29 CFR 1910.132 When engineering controls, work practices, and administrative controls are infeasible or do not provide sufficient protection, employers must provide appropriate personal protective equipment (PPE) and ensure its proper use. PPE is worn to minimize exposure to a variety of workplace hazards. PPE can include protection for eyes, face, head, and extremities. Gowns, face shields, gloves, and respirators are examples of commonly used PPE within healthcare facilities. Employers must conduct a workplace hazard assessment to determine if hazards are present that necessitate the use of PPE. The employer must verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated; the person certifying that the evaluation has been performed; the date(s) of the hazard assessment; and, which identifies the document as a certification of hazard assessment. Based on the hazard assessment, employers are to select PPE that will protect employees from the identified hazards. Employees are to receive training to ensure that they understand the hazards present, the necessity of the PPE, and its limitations. In addition, they must learn how to properly put on, take off, adjust, and wear PPE. Finally, employees must understand the proper care, maintenance, and disposal of PPE. Healthcare employers can receive more information about the Personal Protective Equipment standard at http://www.osha.gov/SLTC/personalprotectiveequipment/index.html. [Table of Contents] Bloodborne Pathogens Standard - 29 CFR 1910.1030 OSHA's Bloodborne Pathogens standard is a regulation that protects employees against health hazards related to the occupational exposure to blood-borne pathogens. The standard applies to any employee who is occupationally exposed to human blood or certain other potentially infectious materials (e.g., pleural fluid, any body fluids visibly contaminated with blood, any unfixed human tissue or organ). The Bloodborne Pathogens standard has provisions requiring exposure control plans, engineering and work practice controls, PPE, hepatitis B vaccination, hazard communication, training, and recordkeeping. Additional information on the Bloodborne Pathogens standard is available at http://www.osha.gov/SLTC/bloodbornepathogens/index.html. [Table of Contents] General Duty Clause In addition to compliance with the hazard-specific safety and health standards, employers must provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. Employers can be cited for violating the General Duty Clause of the OSH Act if they do not take reasonable steps to abate or address such recognized hazards. 2 [Table of Contents] References [Table of Contents] Appendix A Pandemic Influenza Internet Resources
[Table of Contents] Appendix B Infection Control Communication Tools for Healthcare Workers [Table of Contents] Appendix B-1 Factors Influencing Adherence to Hand Hygiene Practices Reproduced from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. Guideline for Hand Hygiene in Healthcare Settings, Box 1. [Table of Contents] Appendix B-2 Elements of Healthcare Worker Educational and Motivational Programs Reproduced from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. Guideline for Hand Hygiene in Healthcare Settings, Box 2. [Table of Contents] Appendix B-3 Strategies for Successful Promotion of Hand Hygiene in Hospitals Adapted from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. Guideline for Hand Hygiene in Healthcare Settings, Table 9. Strategies for Successful Promotion of Hand Hygiene in Hospitals. [Table of Contents] Appendix B-4 Pandemic Influenza Precautions for Veterans Administration Healthcare Facility Staff Reproduced with permission from the Department of Veterans Affairs Pandemic Plan, Appendix E-2: Chart of Pandemic Influenza Precautions for VA Healthcare Facility Staff. Airborne Infection Isolation and Contact Precautions, in addition to Standard Precautions This combination of precautions offers the best protection for health care facility staff, especially at the onset of a pandemic before transmission patterns are well understood.
Droplet Precautions, in addition to Standard Precautions This combination of precautions should be used if droplet transmission appears to be the common mode of transmission or when incapable of using Airborne Infection Isolation and Contact Precautions.
[Table of Contents] Appendix B-5 Public Health Measures Against Pandemic Influenza for Individuals, Healthcare Providers, and Organizations Reproduced with permission from Department of Veterans Affairs Pandemic Plan, Appendix E-3: Chart of Public Health Measures Against Pandemic Influenza Precautions for Individuals, Health Care Providers, and Organizations. The measures in the chart below may be important to reduce transmission of pandemic influenza in VA facilities and other settings.
[Table of Contents] Appendix C Implementation and Planning for Respiratory Protection Programs in Healthcare Settings Appendix C-1 Respiratory Protection Programs OSHA Respiratory Protection Standard The OSHA Respiratory Protection standard (29 CFR 1910.134) requires employers to establish and maintain a respiratory protection program to protect their respirator-wearing employees. Employers must provide respirators when such equipment is necessary to protect the health of employees. The respirator provided must be suitable for its intended purpose. When an employer is required to provide respirators, the employer must establish and maintain a respiratory protection program. Respiratory Protection Program A respiratory protection program is a cohesive collection of worksite-specific procedures and policies that addresses all respiratory protection elements required by the standard. For example, a respiratory protection program must contain specific procedures describing how respirators will be selected, fitted, used, maintained and inspected in a particular workplace. A written program is needed because health and safety programs can be more effectively implemented and evaluated if the procedures are available in a written form for study and review. Also, a written respiratory protection program is the best way to ensure that the unique characteristics of the worksite are taken into account. Developing the written program encourages the employer to thoroughly assess and document information pertaining to the respiratory hazards to which their employees will potentially be exposed, both during normal operating conditions and during reasonably foreseeable emergencies. A respiratory protection program is required to include the following elements (as applicable):
The employer must designate a program administrator to run the program and evaluate its effectiveness. An individual is qualified to be a program administrator if he or she has appropriate training or experience in accord with the program's level of complexity. This training or experience is appropriate if it enables the program administrator to fulfill the minimum standard requirements of recognizing, evaluating, and controlling the hazards in the workplace. For example, if the program requires air-supplying respirators for use in immediately dangerous to life or health environments, the program administrator must have training and experience pertaining to the use of this type of equipment. Similarly, if air-supplying respirators are not used and there are no significant respiratory hazards at the workplace, someone with less sophisticated experience or training might be able to effectively serve in this position. Ultimately, the appropriate qualifications for the respiratory protection program administrator must be determined based on the particular respiratory hazards that exist, or that are reasonably anticipated, at the workplace. Medical Evaluations Employers must medically evaluate their employees' ability to wear a respirator. Medical evaluations are required for both positive pressure and negative pressure respirators. Medical evaluation can be performed by using a medical questionnaire or by performing an initial medical examination that obtains the same information as the medical questionnaire. Employers must allow the employee to be evaluated during the employee's normal working hours or at a time that is convenient to the employee, and employers are responsible for paying for this service (even if the employee has coverage under an insurance plan). Employers must identify a physician or another licensed healthcare professional (PLHCP) to perform the medical evaluations. Physicians are not the only healthcare professionals allowed to perform medical evaluations for respirator use. The Respiratory Protection standard allows any PLHCP to administer the medical questionnaire (described below) or to conduct the medical examination if doing so is within the scope of the PLHCP's license. Employers may check with PLHCPs in their local area to see if performing the medical evaluation is within the scope of their professional license, or employers may check with the state's licensing board. The Medical Questionnaire The medical questionnaire is designed to identify general medical conditions that place employees who use respirators at risk of serious medical consequences. If employers choose to use the medical questionnaire to conduct the medical evaluation, they must use the questionnaire contained in the Respiratory Protection standard (Appendix C of the standard, Part A., Sections 1 and 2). The PLHCP determines whether or not Part B of the questionnaire needs to be administered, and the PLHCP can alter the questions in Part B in any manner he or she thinks is appropriate. Employers may choose to use medical examinations in place of the questionnaire, but they are not required to do so. Medical examinations must be provided for an employee who gives a positive response to any question among questions 1-8 of Part A, Section 2 in Appendix C of the standard. Although the questionnaire does not have to be administered during the medical examination, the PLHCP must obtain the same information from the employee that is contained in the questionnaire. Fit Testing The Respiratory Protection standard requires employers to conduct fit testing on all employees who are required to wear a respirator that includes a tight-fitting facepiece. Fit testing is a procedure used to determine how well a respirator "fits"- that is, whether the respirator forms an adequate seal on the user's face. If a good facepiece-to-face seal is not achieved, the respirator will provide a lower level of protection than it was designed to provide. For example, without a good seal, the respirator can allow contaminants to leak into the face-piece and be inhaled by the user. There are two types of fit testing: quantitative and qualitative. Quantitative fit testing is a method of measuring the amount of leakage into a respirator. It is a numeric assessment of how well a respirator fits a particular individual. To quantitatively fit test a respirator, sampling probes or other measuring devices must be placed to measure aerosol concentrations both outside and on the inside of the respirator facepiece. Qualitative fit testing is a non-numeric pass/fail test that relies on the respirator wearer's response to a substance ("test agent") used in the test to determine respirator fit. In qualitative fit testing, after performing user seal checks, the respirator wearer stands in an enclosure and a test agent is introduced, such as banana oil (isoamyl acetate), saccharin, Bitrex, or irritant smoke (without a test enclosure). If the individual can smell or taste the test agent (or is irritated by the smoke), this indicates that the agent leaked into the facepiece and that the respirator has failed the test because a good facepiece-to-face seal has not been achieved. If the employee cannot successfully complete the qualitative test with a particular respirator, the employee must then be tested with another make, size, or brand of respirator. Fit testing must be conducted for all employees required to wear tight-fitting facepiece respirators as follows:
Employers must ensure that all fit testing conducted for employees required to wear tight-fitting facepiece respirators follows the OSHA approved protocols. Detailed protocols for qualitative and quantitative fit testing are provided as part of the standard (see Appendices A and B of the standard). These protocols specify that you must have on hand during fit testing all types and sizes of respirators that are available for use at the worksite. This allows you to ensure that each employee is tested with the same type of respirator (make, model, style, and size) that he or she will wear at the worksite. Tight-Fitting and Loose-fitting Respirator Facepieces A tight-fitting facepiece is intended to form a complete seal with the respirator wearer's face. This seal must be sufficiently tight to prevent any contaminants in the work environment from leaking around the edges of the facepiece into the user's breathing air. In contrast, a loose-fitting facepiece is specifically designed to form a partial seal with the user's face. Such a facepiece typically covers at least the head and includes a system through which clean air is distributed into the breathing zone. For example, hoods and helmets are loose-fitting facepieces. Such equipment does not rely on a tight facepiece-to-face seal to protect the wearer, and is useful for employees with facial hair or other physical characteristics that make it difficult to wear a tight-fitting facepiece. Preventing Leaks in the Facepiece Seal Facepiece seals and valves are important in tight-fitting respirators. Tight-fitting respirators have a complete seal to the face. If there is a leak in the seal of a tight-fitting respirator or valve, then the respirator cannot reduce the wearer's exposures to respiratory hazards. You must be sure that nothing interferes with the seal of the respirator to the employee's face or with the valves. Conditions that can interfere with the seal or valve include:
Conducting User Seal Checks To conduct a user seal check, the employee performs a negative or positive pressure fit check. For the negative pressure check, the employee:
For the positive pressure check, the employee:
Maintenance and Care of Respirators Employers must provide respirator users with equipment that is clean, sanitary, and in good working order. To accomplish this, employers must have a system of respirator care and maintenance as a component of their respiratory protection program. Regular care and maintenance is important to ensure that the equipment functions as designed and protects the user from the threat of illness or death. Your system of respirator care and maintenance must provide for:
Respirator equipment must be regularly cleaned and disinfected according to specified procedures (see Appendix B-2 of the standard) or according to manufacturer specifications that are of equivalent effectiveness. Cleaning and disinfection procedures are divided into the following:
Proper Storage Procedures for Respirators Employers must store respirators in a manner that:
Employee training is a critical part of a successful respiratory protection program and is essential for correct respirator use. Employers must provide training to their employees who are required to wear respirators and must ensure that each employee can demonstrate knowledge of at least the following:
Retraining Employers must retrain employees in the proper use of respirators annually. They must also retrain employees when:
Appendix C-2 Readiness Plan for Epidemic Respiratory Infection: A Guideline for Operations for Use by the Dartmouth-Hitchcock Medical Center-Lebanon Campus and the Dartmouth College Health Service Reproduced with permission Readiness Plan for Epidemic Respiratory Infection: A Guideline for Operations for Use by the Dartmouth-Hitchcock Medical Center - Lebanon Campus and the Dartmouth College Health Service DHMC, 2005 Developed by Kathy Kirkland, MD, Hospital Epidemiologist, and the DHMC Readiness Committee Background: The Readiness Plan for Epidemic Respiratory Infection (ERI) evolved from our initial response and planning for the prevention and control of Severe Acute Respiratory Syndrome (SARS) which began in the spring of 2003. During those planning activities it became clear that DHMC needs to maintain a level of readiness at all times for a variety of contagious respiratory infections with epidemic potential. Potential threats include SARS or a new strain of influenza that becomes pandemic. Many elements of the plan will make us more prepared to identify and contain other contagious respiratory infections as well, including pertussis, mycoplasma, and parainfluenza, for example. The DHMC plan builds on guidelines from state and federal health authorities which recommend aggressive implementation of respiratory hygiene practices and universal administration of influenza vaccine to healthcare workers and high-risk patients for all healthcare facilities regardless of the presence of an epidemic. This document outlines a plan for responding to various levels of threat posed by ERIs, and an approach to stepping up prevention and control activities as the threat increases. It is based on the premises that we should be vigilant at all times for syndromes that may represent contagious respiratory infection, and that we should maintain a group of people prepared to actively respond to changing situations by implementing appropriate parts of this plan, when indicated. The document is divided into:
Epidemic Respiratory Infection ALERT MATRIX Six levels of alert corresponding to the type of transmission, the location of the cases, and the presence and type of cases at DHMC or DC.
The alert level will be determined by the Readiness Committee, using this matrix and data collected through surveillance activities. It can be upgraded (or downgraded) by the committee depending on the number of cases, or for other compelling circumstances. At each level of alert, the Readiness Committee will consider implementing certain actions. As the level of alert becomes higher, additional actions are added to the actions initiated at the lower level. Level: READY Baseline activities to ensure preparedness in the absence of known active epidemic of ERI in the world Goals
Confirmed efficient human-to-human transmission of potentially epidemic contagious respiratory infection present outside the U.S. and bordering countries (Canada and Mexico) Summary: At the "GREEN" level, our basic activities remain similar to the "READY" level, except that there may be more focused surveillance and screening based on specific geographic and epidemiologic risk factors, and more aggressive forms of isolation may be required for suspected cases. Vigilance of all staff is required to identify potential cases of ERI remains critical. At the GREEN level, the following additional actions will be considered for implementation by the Readiness Committee. Access Control
Confirmed human-to-human transmission of potentially epidemic contagious respiratory infection documented in the U.S. or bordering countries (Canada or Mexico) Summary: At the "YELLOW" level, the ERI is closer to home, and may pose a more real threat. Vigilance of all to identify potential cases of ERI remains critical. At the YELLOW alert level, rapid changes in the epidemiology of disease and the level of threat to DHMC may be expected. The major change is that the Readiness Committee becomes more active so that a rapid change to a higher level of alert is possible. The following additional activities will be considered. Access Control
A case of ERI has been diagnosed at DHMC or Dartmouth College or is an inpatient at DHMC but there has been no documented nosocomial or community spread from this person to others. Summary: When there is a patient with suspected ERI at DHMC, because of the potential for transmission in the hospital setting, the alert level immediately is raised to a form of ORANGE. (i.e., with a single imported case, we immediately would go from READY or GREEN to CONTROLLED ORANGE.) At the "CONTROLLED ORANGE" level, more caution is needed, and our activities shift from more passive to more active control measures. The goal is to prevent nosocomial spread to employees and patients within DHMC. At this level, activation of a number of new measures is considered, relating to access, screening, and clinical care, but there is an effort to maintain relatively normal operations at DHMC except in the area where a potentially infected patient is being cared for. The emphasis is on personal protection of staff and patients, and a readiness to raise the alert level quickly if there is any indication of spread. Access Control
There is evidence of nosocomial transmission of ERI from known infected patients to other patients, employees, or visitors at DHMC, OR there is human-to-human transmission in the Upper Valley region, or nearby. Summary: " ORANGE" indicates a high level of alert, with restrictions on access to DHMC, much more active screening, and a shift away from normal operations throughout the institution. At the ORANGE level, the Readiness Committee will consider implementing each of the following additional actions. Access Control
There is evidence of untraceable or uncontrolled nosocomial transmission of ERI OR there is widespread human-to-human transmission in the Upper Valley region, or nearby Summary: "RED" indicates the highest level of alert, with extreme restrictions on access to DHMC and a major shift away from normal operations throughout the institution. The following additional actions will be considered. Access Control
Appendix 1 Epidemic Respiratory Infections Patient Flow Appendix 2 Suspected or Confirmed Epidemic Respiratory Infection (ERI) Outpatient Management Protocol The following protocol will be followed when a patient has a new cough and risk factors associated with a specific epidemic respiratory infection (ERI). Principles to follow in care of ERI patient.
Appendix 3 Suspected or Confirmed Epidemic Respiratory Infections (ERI) Inpatient Management Protocol This plan will be put into effect when a patient is believed to meet the criteria for an epidemic respiratory infection by one of the Infectious Disease physicians and needs hospitalization. Principles to follow in care of ERI patient
The ERI patient will be admitted to the Hospitalist service, adult or pediatric, with mandatory consultation with Infectious Disease and Critical Care Service on admission. Transfer to the Critical Care Service should be made as soon as a patient shows signs of respiratory distress, i.e., increasing O2 requirement, FI02 > 50, respiratory therapy assessment. Patient Placement All patients, adult and pediatric, will be admitted to 3W. The first case will be admitted to room 301. (If the first patient is critically ill, requiring immediate intensive care they should be admitted to a negative pressure room in the ICU for an adult or the PICU for a child.)
Pediatric patients will be admitted to the rooms on 3West (not the Pedi/Adolescent unit). Nursing staff from the Pedi/Adolescent unit will provide care to the pediatric patient on 3West. If the number of ERI patients exceeds the number of available private negative pressure rooms patients with known ERI can be cohorted together. The following patients will be given priority for the private negative pressure rooms; these decisions will be made in collaboration with the ACOS, Infectious Disease, Infection Control, and Admitting.
The ACOS will work with Admitting and the 3W staff to expedite the admission. (The patient will remain where s/he has been evaluated until the inpatient room is ready.) The ACOS will:
Guidelines for moving ERI patients in DHMC
Anyone entering the room must wear respiratory protection appropriate to the disease. If the disease is transmitted via the airborne route then the following is required.
N95 masks will not be reused. They will be disposed in the trash of as soon as they are removed. PAPR units must be disinfected as soon as they are removed. The person who used the equipment is responsible for cleaning it and plugging in the motor unit to recharge while it is not in use. The hood and hose must be wiped with a disinfectant before being handled and used again. The motor unit should be wiped with a disinfectant if it has been in contact with respiratory secretions. Room Setup Both doors to rooms 301 and 302 must be kept closed. When other rooms are used, the single door to the room must be kept closed. Only essential equipment should be in the room. Equipment brought into the room should be left in the room for use only by that patient. Thermometer, stethoscope glucometer, pulse oyx, should remain in the room. A thermometer can be obtained from CSR, a glucometer can be obtained from Point of Care Testing, ext 57198, in the lab, pulse oyx can be obtained from respiratory therapy. Equipment that cannot be left in the room must be disinfected before it is used for any other patient. Most equipment can be disinfected by cleaning thoroughly with Dimension III. Linen requires no special precautions. Used linen should be handled as little as possible. It should be carefully rolled together in a manner that avoids shaking, and placed in the yellow linen bags. Trash requires no special precautions. Routine waste should be placed in the regular trash bags. Any waste that is saturated with blood or body fluids should be disposed of in the tan bags. Regular dishes will be used. The dietary aide will give the tray to the nurse who will bring it into the room. The nurse will also bring the tray out of the room when the meal is finished. Blood and other specimens may be sent to the lab via normal mechanisms. Be sure the outside of the biohazard bag does not become contaminated. The patient room should be cleaned daily and as needed by housekeeping. While the patient is in the room the housekeeping staff must wear N95 mask and goggles or a PAPR unit and gloves and gowns while in the room. Routine cleaning with a disinfectant is adequate. When the patient is discharged the room should be left closed for an hour, then people may enter without masks to clean. Staffing Nursing staff from Pediatrics and the Critical Care units will provide care to pediatric or critical care patients on 3W. The registered nurse taking care of a ERI patient will not care for any other patients. Other staff members such as LNAs who may be needed to assist with care may care for other patients. The goal is to limit the number of employees who enter the room while providing appropriate safe care for the patient. All employees will be expected to participate in the care of ERI patients as needed. Pregnant employees will not be excused from caring for ERI patients. Staff who are taking care of ERI patients may wear hospital supplied scrub uniforms. (There is a cabinet in Stores that has a few scrubs available for emergency use, a larger supply will need to be ordered from the linen department.) Staff who have cared for a ERI patient may shower in their locker room before leaving work. Employee Surveillance A list of all employees who enter the room or have had close contact with the patient will be started by Infection Control as soon as the ERI plan is activated and maintained by the RN who is assigned to the patient. All employees entering the room or who have contact with the ERI patient must add their name and contact information to the list. The unit secretary will FAX the prior day's list to Occupational Medicine (FAX 650-0928) between 8:00 and 9:00 a.m. each day. These employees will be followed by Occupational Medicine for symptoms of the disease. Occupation Medicine will develop a disease-specific protocol for close monitoring of all employees who have had contact with the ERI patient. Visitors No visitors. People can talk to the patient via telephone. For pediatric patients, one parent may be allowed in the room. They will need to use PPE and follow policies as above. They may not sleep in the room. Special Situations Cough inducing or aerosol producing procedures (intubation, sputum induction, nebulizer treatment, CPAP, BiPAP, suctioning) should not be done unless absolutely necessary. If they must be done the patient should be medicated if possible to limit aerosol production (sedate, paralyze). The absolute minimum number of employees should be in the room. Employees who are in the room during such a procedure must wear PAPR units. To the extent possible all tests and procedures will be done in the patient's room. Medically necessary tests that cannot be done in the patient's room need to be planned and coordinated with the department doing the test so that the patient does not wait in the department's waiting area, as few staff as possible are present and they have appropriate PPE, as few other patients as possible are in the area. The room and equipment must be appropriately cleaned after the patient leaves and before another patient is seen. If surgery is needed it should be done at a time when as few other patients as possible are in the OR. The patient should be brought directly into the OR, not wait in the holding area. As few staff as possible should be in the room. The OR staff in the room should all wear N95 masks and goggles as well as other appropriate PPE. If the patient needs dialysis, this will be done in the patient's room. The patient will not go to the dialysis unit. In the event of cardiopulmonary arrest a Protected Code Blue will be called. Only 6 members of the code team will be in the room. They must all wear the appropriate PPE; PAPR unit, gloves and gown. Equipment and supplies must go in only one direction (equipment and supplies that are taken off the code cart are not put back on the cart). Cohorting of Patients and Staff If there is significant ERI transmission in the facility or frequent unprotected exposures then patients and staff may need to be cohorted in separate areas of the facility according to their exposure status;
Hospitalist Service_____________________________________________________ Critical Care Service ___________________________________________________ Pediatric Service ______________________________________________________ Infectious Disease Service ______________________________________________ Occupational Medicine Department _______________________________________ Emergency Department_________________________________________________ GIM Clinic____________________________________________________________ Admitting Department__________________________________________________ ACOS _______________________________________________________________ Nursing Director for 3W_________________________________________________ Nursing Director for Pediatrics ___________________________________________ Nursing Director for Critical Care _________________________________________ Housekeeping Department_______________________________________________ Engineering __________________________________________________________ Perioperative Services__________________________________________________ CPR Committee _______________________________________________________ Respiratory Therapy ___________________________________________________ Security_____________________________________________________________ Transportation________________________________________________________ Laboratory___________________________________________________________ Risk Management______________________________________________________ [Table of Contents] Appendix D Self-Triage and Home Care Resources for Healthcare Workers and Patients Appendix D-1 Sample Self-Triage Algorithm for Persons with Influenza Symptoms Reproduced with permission from the Department of Veterans Affairs, VA Pandemic Influenza Plan Appendix E-5: SAMPLE Self-Triage Algorithm for Persons with Influenza Symptoms. You may have influenza (flu). When should you seek additional help from a healthcare provider? The symptoms of influenza are:
If you have some of these symptoms:
But IF you Or IF you CALL your healthcare provider GO RIGHT AWAY for healthcare [Table of Contents] Appendix D-2 Home Care Guide for Influenza Reproduced with permission from the Department of Veterans Affairs, VA Pandemic Influenza Plan Appendix E-6, Home Care Guide for Influenza: Symptom and Care Log, Infection Control Measures for the Home. A person with influenza will often become ill very suddenly. Fever and the worst symptoms often last three days, but sometimes last as many as eight days. The person may feel weak, tired, or less energetic than normal for weeks afterward, and may have a long-lasting hacking cough. Common symptoms: Fever-low (99 ˚ F) to high (104 ˚ F), usually for 3 days, but may persist for 4 to 8 days. Sometimes fever will go away and return a day later.
(Copy, fill out, and bring log sheets to healthcare provider visits) Name of patient______________________________________________________________________ Name of healthcare provider_____________________________________________________________
* How the person looks; what the person is doing; fluids or foods taken since the last observation. [Table of Contents] Appendix E References for Diagnosis and Treatment of Staff During an Influenza Pandemic Please refer to www.pandemicflu.gov or http://www.pandemicflu.gov/vaccine/#testing for current information and recommendations. Reproduced from the CDC Influenza (Flu) Laboratory Diagnostic Procedures for Influenza webpage, http://www.cdc.gov/flu/professionals/labdiagnosis.htm. Last accessed March 6, 2007. Appendix E-1. Influenza Diagnostic Table
Footnotes
Appendix F Pandemic Planning Checklists and Example Plans
Appendix F-1 Sample Emergency Management Program Standard Operating Procedure (SOP) Reproduced with permission from the Department of Veterans Affairs Pandemic Plan, Appendix D-2: Sample Emergency Management Program Standard Operating Procedure (SOP). Pandemic Influenza Affecting A VA Healthcare Facility (Modify for your facility) Emergency Management Program Guidebook Department of Veterans Affairs THE DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER (LOCATION) EMERGENCY MANAGEMENT PROGRAM (DATE) STANDARD OPERATING PROCEDURE NO. ( ) SUBJECT: VA Health Care Facility's Preparation and Response to an Influenza Pandemic Description of the Threat/Event.
The mode(s) of transmission, degree of morbidity and mortality, and amount of societal disruption that a pandemic influenza might cause will be uncertain until the specific influenza strain is identified and observed. From applying what is known about seasonal influenza, it might be expected that a pandemic influenza would follow some of the same transmission patterns: ready transmission by respiratory droplets (and perhaps by aerosolized particles) from person to person; shedding and transmission of virus before persons are ill, a short incubation period of approximately 2 days, and thus a potential doubling of cases every 2 to 3 days.
(NAME) Chief, (SERVICE NAME) Attachment: Key Activity Management Tool/Structure [Table of Contents] Appendix G Risk Communication Resources
Appendix G-1 Risk and Crisis Communication: 77 Questions Commonly Asked by Journalists During a Crisis (Reproduced with permission from: Covello, V.T., "Risk Communication and Message Mapping: A New Tool for Communicating Effectively in Public Health Emergencies and Disasters," Journal of Emergency Management, Vol.#4 No.#3, 25-40 (2006)). Journalists are likely to ask six questions in a crisis (who, what, where, when, why, how) that relate to three broad topics: (1) What happened?; (2) What caused it to happen?; (3) What does it mean? Specific questions include:
Appendix H Sample Supply Checklists For Pandemic Planning Appendix H-1 Examples of Consumable and Durable Supply Needs Reproduced and modified from the HHS Pandemic Influenza Plan Supplement 3 Health Care Planning, Box 2.
[Table of Contents] Appendix H-2 Suggested Inventory of Durable and Consumable Supplies for Veterans Administration Health Care Facilities during a Pandemic Influenza Reproduced with permission from Department of Veterans Affairs, VA Pandemic Plan Durable resources
OSHA Assistance OSHA can provide extensive help through a variety of programs, including technical assistance about effective safety and health programs, state plans, workplace consultations, voluntary protection programs, strategic partnerships, training and education, and more. An overall commitment to workplace safety and health can add value to your business, to your workplace, and to your life. [Table of Contents] Safety and Health Program Management Guidelines Effective management of employee safety and health protection is a decisive factor in reducing the extent and severity of work-related injuries and illnesses and their related costs. In fact, an effective safety and health program forms the basis of good employee protection and can save time and money (about $4 for every dollar spent) and increase productivity and reduce employee injuries, illnesses, and related workers' compensation costs. To assist employers and employees in developing effective safety and health programs, OSHA published recommended Safety and Health Program Management Guidelines (54 Federal Register (16): 3904-3916, January 26, 1989). These voluntary guidelines can be applied to all places of employment covered by OSHA. The guidelines identify four general elements critical to the development of a successful safety and health management system:
[Table of Contents] State Programs The Occupational Safety and Health Act of 1970(OSH Act) encourages states to develop and operate their own job safety and health plans. OSHA approves and monitors these plans. Twenty-four states, Puerto Rico and the Virgin Islands currently operate approved state plans: 22 cover both private and public (state and local government) employment; Connecticut, New Jersey, New York and the Virgin Islands cover the public sector only. States and territories with their own OSHA-approved occupational safety and health plans must adopt standards identical to, or at least as effective as, the Federal OSHA standards. [Table of Contents] Consultation Services Consultation assistance is available on request to employers who want help in establishing and maintaining a safe and healthful workplace. Largely funded by OSHA, the service is provided at no cost to the employer. Primarily developed for smaller employers with more hazardous operations, the consultation service is delivered by state governments employing professional safety and health consultants. Comprehensive assistance includes an appraisal of all mechanical systems, work practices, and occupational safety and health hazards of the workplace and all aspects of the employer's present job safety and health program. In addition, the service offers assistance to employers in developing and implementing an effective safety and health program. No penalties are proposed or citations issued for hazards identified by the consultant. OSHA provides consultation assistance to the employer with the assurance that his or her name and firm and any information about the workplace will not be routinely reported to OSHA enforcement staff. Under the consultation program, certain exemplary employers may request participation in OSHA's Safety and Health Achievement Recognition Program (SHARP). Eligibility for participation in SHARP includes receiving a comprehensive consultation visit, demonstrating exemplary achievements in workplace safety and health by abating all identified hazards, and developing an excellent safety and health program. Employers accepted into SHARP may receive an exemption from programmed inspections (not complaint or accident investigation inspections) for a period of 1 year. For more information concerning consultation assistance, see OSHA's website at www.osha.gov. [Table of Contents] Voluntary Protection Programs (VPP) Voluntary Protection Programs and on-site consultation services, when coupled with an effective enforcement program, expand employee protection to help meet the goals of the OSH Act. The VPPs motivate others to achieve excellent safety and health results in the same outstanding way as they establish a cooperative relationship between employers, employees, and OSHA. For additional information on VPP and how to apply, contact the OSHA regional offices listed at the end of this publication. [Table of Contents] Strategic Partnership Program OSHA's Strategic Partnership Program, the newest member of OSHA's cooperative programs, helps encourage, assist, and recognize the efforts of partners to eliminate serious workplace hazards and achieve a high level of employee safety and health. Whereas OSHA's Consultation Program and VPP entail one-on-one relationships between OSHA and individual worksites, most strategic partnerships seek to have a broader impact by building cooperative relationships with groups of employers and employees. These partnerships are voluntary, cooperative relation-ships between OSHA, employers, employee representatives, and others (e.g., trade unions, trade and professional associations, universities, and other government agencies). For more information on this and other cooperative programs, contact your nearest OSHA office, or visit OSHA's website at www.osha.gov [Table of Contents] Alliance Program Through the Alliance Program, OSHA works with groups committed to safety and health, including businesses, trade or professional organizations, unions and educational institutions, to leverage resources and expertise to develop compliance assistance tools and resources and share information with employers and employees to help prevent injuries, illnesses and fatalities in the workplace. Alliance Program agreements have been established with a wide variety of industries including meat, apparel, poultry, steel, plastics, maritime, printing, chemical, construction, paper and telecommunications. These agreements are addressing many safety and health hazards and at-risk audiences, including silica, fall protection, amputations, immigrant workers, youth and small businesses. By meeting the goals of the Alliance Program agreements (training and education, outreach and communication, and promoting the national dialogue on workplace safety and health), OSHA and the Alliance Program participants are developing and disseminating compliance assistance information and resources for employers and employees such as electronic assistance tools, fact sheets, toolbox talks, and training programs. [Table of Contents] OSHA Training and Education OSHA area offices offer a variety of information services, such as compliance assistance, technical advice, publications, audiovisual aids and speakers for special engagements. OSHA's Training Institute in Arlington Heights, IL, provides basic and advanced courses in safety and health for Federal and state compliance officers, state consultants, Federal agency personnel, and private sector employers, employees, and their representatives. The OSHA Training Institute also has established OSHA Training Institute Education Centers to address the increased demand for its courses from the private sector and from other federal agencies. These centers are nonprofit colleges, universities, and other organizations that have been selected after a competition for participation in the program. OSHA also provides funds to nonprofit organizations, through grants, to conduct workplace training and education in subjects where OSHA believes there is a lack of workplace training. Grants are awarded annually. Grant recipients are expected to contribute 20 percent of the total grant cost. For more information on grants, training, and education, contact the OSHA Training Institute, Office of Training and Education, 2020 South Arlington Heights Road, Arlington Heights, IL 60005, (847) 297-4810, or see Outreach on OSHA's website at www.osha.gov. For further information on any OSHA program, contact your nearest OSHA regional office listed at the end of this publication. [Table of Contents] Information Available Electronically OSHA has a variety of materials and tools available on its website at www.osha.gov. These include electronic compliance assistance tools, such as Safety and Health Topics, eTools, Expert Advisors; regulations, directives and publications; videos and other information for employers and employees. OSHA's software programs and compliance assistance tools walk you through challenging safety and health issues and common problems to find the best solutions for your workplace. A wide variety of OSHA materials, including standards, interpretations, directives and more can be purchased on CD-ROM from the U.S. Government Printing Office, Superintendent of Documents, toll-free phone (866) 512-1800. OSHA Publications OSHA has an extensive publications program. For a listing of free or sales items, visit OSHA's website at www.osha.gov or contact the OSHA Publications Office, U.S. Department of Labor, 200 Constitution Avenue, NW, N-3101, Washington, DC 20210: Telephone (202) 693-1888 or fax to (202) 693-2498. [Table of Contents] Contacting OSHA To report an emergency, file a complaint, or seek OSHA advice, assistance, or products, call (800) 321OSHA or contact your nearest OSHA Regional or Area office listed at the end of this publication. The teletypewriter (TTY) number is (877) 889-5627. Written correspondence can be mailed to the nearest OSHA Regional or Area Office listed at the end of this publication or to OSHA's national office at: U.S. Department of Labor, Occupational Safety and Health Administration, 200 Constitution Avenue, N.W., Washington, DC 20210. By visiting OSHA's website at www.osha.gov, you can also:
OSHA Regional Offices
Note: To get contact information for OSHA Area Offices, OSHA-approved State Plans and OSHA Consultation Projects, please visit us online at www.osha.gov or call us at 1-800-321-OSHA. [Table of Contents] |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Back to Top | www.osha.gov | www.dol.gov |
Contact Us | Freedom of Information Act | Customer Survey Privacy and Security Statement | Disclaimers |
||
Occupational Safety & Health Administration 200 Constitution Avenue, NW Washington, DC 20210 |
Page last updated: 09/12/2007 |