Edwin G. Foulke, Jr.
Assistant Secretary of Labor for
Occupational Safety and Health

• The delivery of healthcare services requires a broad range of employees, such as first responders, nurses, physicians, pharmacists, technicians and aides, building maintenance, security and administrative personnel, social workers, laboratory employees, food service, housekeeping, and mortuary personnel. Moreover, these employees can be found in a variety of workplace settings, including hospitals, chronic care facilities, outpatient clinics (e.g., medical and dental offices, schools, physical and rehabilitation therapy centers, health departments, occupational health clinics, and prisons), free-standing ambulatory care and surgical facilities, and emergency response settings.
• The diversity among healthcare workers and their workplaces makes preparation and response to a pandemic influenza especially challenging. For example, not all employees in the same healthcare facility will have the same risk of acquiring influenza, not all individuals with the same job title will have the same risk of infection, and not all healthcare facilities will be at equal risk although all will be similarly susceptible. During an influenza pandemic, healthcare workers may be required to provide services in newly established healthcare facilities to accommodate patient overflow from traditional healthcare settings (e.g., convention centers, schools, and sports arenas). Consequently, the cornerstone of pandemic influenza preparedness and response is an assessment of risk and the development of effective policies and procedures tailored to the unique aspects of various healthcare settings.

• Clinical background information on influenza
• Infection control
• Pandemic influenza preparedness
• OSHA standards of special importance

1. U.S. Department of Health and Human Services (HHS). Pandemicflu.gov, General Information. Last accessed June 7, 2006:http://www.pandemicflu.gov/general/. [Back]
2. Meltzer M.I., N.J. Cox, K. Fukuda. 1999. The economic impact of pandemic influenza in the United States: priorities for intervention. Emerg Infect Dis 5:659-71. [Back]
3. Thompson W.W., D.K. Shay, E. Weintraub, et al. 2003. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 289:179-86. [Back]
4. Waldhorn R., E. Toner. 2005. Challenges to hospital medical preparedness and response in a flu pandemic. Center for Biosecurity, University of Pittsburgh Medical Center. October 12, 2005. Last accessed June 7, 2006: http://www.upmc-biosecurity.org/facts-hospitalprep.html [Back]

• Seasonal influenza or "flu" refers to periodic outbreaks of acute onset viral respiratory infection caused by circulating strains of human influenza A and B viruses. Seasonal "flu" is the kind of influenza with which healthcare workers and the public are most familiar. In temperate regions of the world, seasonal influenza generally occurs most frequently during the winter months when the humidity and outdoor temperatures are low (generally from December until April in northern temperate regions). Between 5–20 percent of the population may be infected annually. Most people have some immunity to the currently circulating strains of influenza virus and, as a result, the severity and impact of seasonal influenza is substantially less than during pandemics. Each year, a trivalent influenza vaccine is prepared in advance of the anticipated seasonal outbreak and it includes those strains (two type A and one type B) that are expected to be the most likely to circulate in the upcoming "flu" season. Influenza vaccine is currently targeted toward those at greatest risk of influenza-related complications and their contacts, such as healthcare workers.
• Avian influenza, also known as the bird flu, is caused by type A influenza viruses that infect wild birds and domestic poultry. Some forms of the avian influenza are worse than others. Avian influenza viruses are generally divided into two groups: low pathogenic avian influenza and highly pathogenic avian influenza. Low pathogenic avian influenza naturally occurs in wild birds and can spread to domestic birds. In most cases it causes no signs of infection or only minor symptoms in birds. In general, these low pathogenic strains of the virus pose little threat to human health. Low pathogenic avian influenza virus H5 and H7 strains have the potential to mutate into highly pathogenic avian influenza and are, therefore, closely monitored. Highly pathogenic avian influenza spreads rapidly and has a high death rate in birds. Highly pathogenic avian influenza of the H5N1 strain is rapidly spreading in birds in some parts of the world.

• Pandemic influenza refers to a global disease outbreak. A flu pandemic occurs when a new influenza type A 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. Such a virus is likely to have origins from avian viruses or possibly from other animal sources (e.g., pigs). Many scientists believe that since no pandemic has occurred since 1968, it is only a matter of time before another pandemic occurs. A pandemic may occur in waves of outbreaks with each wave in a community lasting 8 to 12 weeks. One-to-three waves may occur.

1. Murphy B.R., R.G. Webster 1996. Orthomyxoviruses. In Fields Virology. Third Edition. Fields B.N., D.M. Knipe, P.M. Howley, editors. Philadelphia, PA: Lippincott-Raven, New York. pp. 1397-445. [Back]
2. Perdue, M.L., D.E. Swayne. 2005. Public Health Risk from Avian Influenza Viruses. Avian Dis 49:317327. September. [Back]
3. HHS. 2006. Pandemic Influenza Plan, Appendix C. U.S. Department of Health and Human Services. Last accessed April 12, 2006: http://www.hhs.gov/pandemicflu/plan/appendixc.html. [Back]
4. CDC. 2005. Pandemic Influenza Key Facts. Centers for Disease Control and Prevention. Last accessed June 6, 2006: http://www.cdc.gov/flu/keyfacts.htm. [Back]
5. HHS. 2005. Pandemic Influenza Plan, Supplement 1. U.S. Department of Health and Human Services. Last accessed February 2, 2005: http://www.hhs.gov/pandemicflu/plan/sup1.html. [Back]
6. HHS. 2005. Pandemic Influenza Plan, Supplement 5. U.S. Department of Health and Human Services. Last accessed February 2, 2006: http://www.hhs.gov/pandemicflu/plan/sup5.html. [Back]
7. CDC. 2006. Influenza Clinical Description and Diagnosis. Centers for Disease Control and Prevention. Last accessed February 2, 2006: http://www.cdc.gov/flu/professionals/diagnosis/ [Back]
8. HHS. 2005. Pandemic Influenza Plan, Appendix B. U.S. Department of Health and Human Services. Last accessed February 2, 2006: http://www.hhs.gov/pandemicflu/plan/appendixb.htm. [Back]
9. Beigel J.H., J. Farrar, A.M. Ham, et al. 2005. Avian influenza A (H5N1) infection in humans. A/H5. N Engl J Med 353(13):1374-85. [Back]
10. Du Ry van Beest Holle M., et al. 2005. Human-to-human transmission of avian influenza A/H7N7, the Netherlands, 2003. Euro Surveill 1;10(12). [Back]
11. Walsh E.E., C. Cox, A.R. Falsey. 2002. Clinical features of influenza A virus infection in older hospitalized persons. J Am Geriatr Soc 50(9):1498-503. September 8. [Back]
12. Monto A.S., S. Gravenstein, M. Elliot, M. Colopy, J. Schweinle. 2000. Clinical signs and symptoms predicting influenza infection. Arch Intern Med 160(21): 3243-7. November 27. Comments in Arch Intern Med 161(10):1351-2. [Back]
13. HHS. 2005. Pandemic Influenza Plan. Supplement 2: Laboratory Diagnostics. U.S. Department of Health and Human Services. Last accessed March 21, 2006: http://www.hhs.gov/pandemicflu/plan/sup2.html. [Back]
14. CDC. 2005. Laboratory Diagnostic Procedures for Influenza. Last accessed March 21, 2006: http://www.cdc.gov/flu/professionals/labdiagnosis.htm. [Back]
15. MMWR. 2006. New laboratory assay for diagnostic testing of avian influenza A/H5. Morbidity and Mortality Weekly Report (MMWR). Last accessed March 21, 2006: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5505a3.htm. [Back]
16. HHS. 2005. Pandemic Influenza Plan, Supplement 4. U.S. Department of Health and Human Services. Last accessed February 20, 2005: http://www.hhs.gov/pandemicflu/plan/sup4.html. [Back]
17. Bridges C.B., M.J. Kuehnert, C.B. Hall. 2003. Transmission of influenza: implications for control in health care settings. Clin Infect Dis 37(8):10941101. [Back]
18. Schulman J.L. 1967. Experimental transmission of influenza virus infection in mice: IV. Relationship of transmissibility of different strains of virus and recovery of airborne virus in the environment of infector mice. J Exp Med 125(3):479-88. [Back]
19. Alford R.H., J.A. Kasel, V. Knight. 1966. Human influenza resulting from aerosol inhalation. Proc Soc Exp Biol Med 122(3):800-804. [Back]
20. Moser M.R., T.R. Bender, H.S. Margolis, G.R. Nobel, A.P. Kendal, D.G. Ritter. 1979. An outbreak of influenza aboard a commercial airliner. Am J Epidemiol 110(1):1-6. July. [Back]
21. Bean, B., B.M. Moore, B. Sterner, L.R. Peterson, D.N. Gerding, H.H. Balfour. 1982. Survival of influenza viruses on environmental surfaces. J Infect Dis 146(1):47-51. July. [Back]
22. Blumenfeld H.L., E.D. Kilbourne, D.B. Louria, D.F. Rogers. 1959. Studies on influenza in the pandemic of 1957-1958. I. An epidemiologic, clinical and serologic investigation of an intrahospital epidemic, with a note on vaccination efficacy. J Clin Invest 38(1 Part 2):199-212. [Back]
23. McLean R.L. 1961. General discussion. Am Rev Respir Dis 83:36-8. [Back]
24. HHS. 2005. Pandemic Flu Plan, Supplement 7. U.S. Department of Health and Human Services. Last accessed February 20, 2006: http://www.hhs.gov/pandemicflu/plan/sup7.html. [Back]
25. MMWR. 2006. Influenza vaccination of health care personnel. Last accessed March 21, 2006: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm. [Back]
26. Wilde, J.A., et al. 1999. Effectiveness of Influenza Vaccine in Health Care Professionals. JAMA March 10, 1999 – Vol 281, No. 10. [Back]
27. Salgado C.D., et al. 2004. Preventing Nosocomial Influenza Infection by Improving the Vaccine Acceptance Rate of Clinicians. Infection Control and Hospital Epidemiology. 2004 Nov: 25(11):923-8. [Back]
28. HHS. 2005. Pandemic Influenza Plan, Appendix D. U.S. Department of Health and Human Services. Last accessed March 21, 2006: http://www.hhs.gov/pandemicflu/plan/appendixd.html. [Back]
29. HHS. 2005. Pandemic Influenza Plan, Supplement 6. U.S. Department of Health and Human Services. Last accessed March 21, 2006: http://www.hhs.gov/pandemicflu/plan/sup6.html. [Back]

• The use of gloves and facial (nose, mouth, and eye) protection by healthcare workers when providing care to coughing/sneezing patients.
• Hand hygiene before and after patient contact, and after removing gloves or other PPE. Routine hand hygiene is performed either by using an alcohol-based hand rub (preferably) or by washing hands with soap and water and using a single-use towel for drying hands. If hands are visibly dirty or soiled with blood or other body fluids, or if broken skin might have been exposed to infectious material, healthcare workers should wash their hands thoroughly with soap and water.
• Standard operating procedures to handle and disinfect patient care equipment, patient rooms, and soiled linen; prevent needlestick/sharp injuries; and address environmental cleaning, spills-management, and handling of waste.

• Putting on PPE (such as gowns) prior to entry into a patient room and taking off PPE prior to exit.
• Dedicating patient care equipment.
• Limiting patient movement.
• Placing the patient in a private room or with patients who have active infection with the same microorganism or who are suspected to have active infection with the same microorganism but with no other infection (cohorting).

• Place patient in a negative pressure room (airborne infection isolation room) or area, if available.
• If a negative pressure room is not available or cannot be created with mechanical manipulation of the air, place patient in a single room.
• If a single room is not available, patients may be cohorted in designated multi-bed rooms or wards.
• Doors to any room or area housing patients must be kept closed when not being used for entry or egress.
• When possible, isolation rooms should have their own handwashing sink, toilet, and bath facilities.
• The number of persons entering the isolation room should be limited to the minimum number necessary for patient care and support.
• HHS/CDC recommends the use of a particulate respirator that is at least as protective as a National Institute for Occupational Safety and Health (NIOSH)-certified N95. 1, 2 For a more complete discussion of respirator use during an influenza pandemic, see the section Respiratory Protection for Pandemic Influenza on page 27.

• Being a physician or a nursing assistant, rather than a nurse
• Wearing gowns/gloves
• Understaffing and overcrowding
• Handwashing agents that cause irritation and dryness
• Lack of knowledge of guidelines
• Perceived lack of institutional priority for hand hygiene

1. They are hot and uncomfortable.
2. They produce "pain spots" if poorly fitted.
3. They interfere with communication and performance.
4. They are not easily accessible when you need them.
5. They put the burden of safety on the wearer rather than the company.
6. They make the wearer look "funny," alarmist, not macho, or unattractive.
7. They produce labored breathing, increased heart rate, and perspiration.
8. They impair vision and can actually be a safety hazard.
9. They produce feelings of claustrophobia and anxiety.

• Senior management support for safety programs
• Absence of workplace barriers to safe work practices
• Cleanliness and orderliness of the worksite
• Minimal conflict and good communications among staff
• Frequent safety-related feedback and training by supervisors
• Availability of PPE and engineering controls 16

• Limit admission of influenza patients to those with severe complications of influenza who cannot be cared for outside the hospital setting.
• Admit patients to either a single-patient room or an area designated for cohorting of patients with influenza.
• If possible, and when practical, use of an airborne isolation room may be considered when conducting aerosol-generating procedures.

• Endotracheal intubation
• Aerosolized or nebulized medication administration
• Diagnostic sputum induction/collection
• Bronchoscopy
• Airway suctioning
• Positive pressure ventilation via face mask (e.g., BiPAP and CPAP )
• High-frequency oscillatory ventilation

• Perform the procedure in a private room, separated from other patients.
• If possible, increase air changes, increase negative pressure relative to the hallway, and avoid recirculation of the room air.
• If recirculation of the air is unavoidable, pass the air through a HEPA filter before recirculation.
• Keep doors closed except when entering or leaving the room, and minimize entry to and exit from the room.

• Designated areas should be used for cohorting pandemic influenza-infected patients. At the height of a pandemic, laboratory testing to confirm pandemic influenza is likely to be limited, in which case cohorting should be based on having symptoms consistent with pandemic influenza. Suspected cases of pandemic influenza should be housed separately from confirmed cases of pandemic influenza.
• Whenever possible, healthcare workers assigned to cohorted patient care units should be experienced healthcare workers and should not "float" or be assigned to other patient care areas.
• The number of persons entering the cohorted area should be limited to the minimum number necessary for patient care and support.
• Limit patient transport by having portable x-ray equipment available in cohort areas, if possible.
• Healthcare workers assigned to cohorted patient care units should be aware that pandemic influenza-infected patients may be concurrently infected or colonized with other pathogenic organisms (e.g., Staphylococcus aureus and Clostridium difficile) and should use standard and applicable transmission-based infection control precautions to prevent transmission of healthcare-associated infections.

• Surgical and procedure masks are appropriate for use by pandemic influenza-infected patients to contain respiratory droplets and should be worn by suspected or confirmed pandemic influenza-infected patients during transport or when care is necessary outside of the isolation room/area.
• Limit the movement and transport of patients from the isolation room/area for essential purposes only. Inform the receiving area/facility as soon as possible, prior to the patient's arrival, of the patient's diagnosis and of the precautions that are indicated. Use mobile diagnostic services (e.g., mobile X-ray and CT scan) when available.
• If transport outside the isolation room/area is required, the patient should wear a surgical mask and perform hand hygiene after contact with respiratory secretions.
• If the patient cannot tolerate a mask (e.g., due to the patient's age or deteriorating respiratory status), instruct the patient (or parent of pediatric patient) to cover the nose and mouth with a tissue during coughing and sneezing, or use the most practical alternative to contain respiratory secretions. If possible, instruct the patient to perform hand hygiene after respiratory hygiene.
• Identify appropriate paths, separated from main traffic routes as much as possible, for entry and movement of pandemic influenza patients in the facility, and determine how these pathways will be controlled (e.g., dedicated pandemic influenza corridors and elevators).
• If there is patient contact with surfaces, these surfaces should be cleaned and disinfected.
• Healthcare workers transporting unmasked patients with suspected or confirmed pandemic influenza-infected patients should wear an N95 or higher NIOSH-certified respirator.

• Educate healthcare workers about recommended infection control precautions for suspected or confirmed pandemic influenza-infected patients. At a minimum, healthcare workers should follow contact and droplet precautions for all patients with acute respiratory illness.
• Ensure that clinicians know where and how to promptly report a pandemic influenza case to hospital and public health officials.
• Communicate planning strategies that address when confirmed pandemic influenza-infected patients have been admitted to the facility, nosocomial surveillance should be heightened for evidence of transmission to other patients and staff.
• Educate healthcare workers and visitors on the correct use of PPE and hand hygiene.
  • Recommended steps for placement and removal of PPE and performance of hand hygiene.
  • Appropriate procedures to select a particulate respirator that fits well.
  • Train persons who will be likely to use particulate respirators on how to put them on and how to perform user seal checks.
• Provide respiratory etiquette educational materials and supplies to coughing individuals.
• Train infection control monitors to observe and correct deficiencies in healthcare worker and visitor adherence to proper hygiene and PPE use.
• Use simulations (i.e., "table top" or other exercises) to test the facility's response capacities. The exercise should be realistic and should continue until limiting factors and deficiencies are identified.
• Develop risk communication materials for healthcare workers, patients, and patient families/visitors.

• Visitors should be provided PPE to comply with recommended precautions and should be instructed on how to properly put on, take off, and dispose of PPE. They should also be instructed on proper hand hygiene practices prior to entry to the patient isolation room/area.
• Communication of policies and procedures to visitors 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.
• Legal guardians of pediatric patients should be allowed, when possible, to accompany the patient throughout the hospitalization.
• Parents/relatives/legal guardians may assist in providing care to pandemic influenza-infected patients in special situations (e.g., lack of resources, pediatric patients, etc.) if adequate training and supervision of PPE use and hand hygiene is ensured.
• Because family members may have been exposed to pandemic influenza via the patient or similar environmental exposures, all family members and visitors should be screened for symptoms of respiratory illness upon entry to the facility.
• Symptomatic family members or visitors should be considered possible pandemic influenza cases and should be evaluated for pandemic influenza infection.

• Promote annual seasonal influenza vaccination among staff and volunteers.
• Communicate with state and local health departments as to the availability of stockpiles of vaccine for the specific pandemic influenza subtype and follow federal and local recommendations for administering the vaccine to healthcare workers.
• Plan for rapid vaccination of healthcare workers as recommended by federal agencies and state health departments, if vaccine for the pandemic influenza virus becomes available.
• Have a system for documentation of influenza vaccination of healthcare workers, since vaccination for pandemic influenza may require two doses.

• When considering antiviral prophylaxis, be sure to evaluate appropriate candidates for contraindications, answer their questions, review adverse effects, and explain the risks and benefits.
• Maintain a log of persons on antiviral medications, persons evaluated and not receiving prophylaxis, doses dispensed, and adverse effects.
• Periodically evaluate and update antiviral prophylaxis policies and procedures.

• Keep a register of healthcare workers who have provided care for pandemic influenza-infected patients (confirmed or probable cases).
• Keep a register of healthcare workers who have recovered from pandemic influenza (confirmed or probable cases).
• Have a healthcare worker influenza-like illness surveillance system in the healthcare facility, including encouragement for self-reporting by symptomatic healthcare workers.
• Have a system to monitor work absenteeism for health reasons, especially in healthcare workers providing direct patient care.
• Screen all healthcare workers providing care to pandemic influenza-infected patients for influenza-like symptoms before each daily shift. Symptomatic healthcare workers should be evaluated and excluded from duty.
• Clinical employees believed to have had significant clinical exposure to a highly pathogenic influenza strain should be evaluated; counseled about the risk of transmission to others; and monitored for fever, respiratory symptoms, sore throat, rhinorrhea (runny nose), chills, rigors, myalgia, headache, and diarrhea.

• Vaccinate healthcare workers against seasonal influenza and monitor compliance.
• Coordinate with public health officials for local policy on antiviral prophylaxis of healthcare workers and assistance for obtaining adequate supplies of neuraminidase inhibitors for prophylaxis of healthcare workers providing care for pandemic influenza-infected patients. 28 Develop a system to provide neuraminidase inhibitors to healthcare workers exposed to pandemic influenza-infected patients according to local and national policies.

• If possible, perform serologic and other testing for pandemic influenza on healthcare workers with influenza-like illness and who have had likely exposures to pandemic influenza-infected patients.
• Healthcare workers with serological evidence of pandemic influenza infection should have protective antibodies against this strain and can be prioritized for the care of pandemic influenza patients. These employees could also be prioritized to provide care for patients who are at risk for serious complications from influenza (e.g., transplant patients and neonates). However, be aware that subsequent "waves" of influenza infection may be caused by a different influenza strain.
• Some healthcare workers have an increased risk of complications due to pandemic influenza (e.g., pregnant women, immunocompromised persons and persons with respiratory diseases). Care should be taken to provide appropriate education, training and policies that comply with federal, state and local laws to adequately protect these employees.
• Healthcare workers who are ill should not be involved in direct patient care since they may be more vulnerable to other infections and may be more likely to develop severe illness if infected with pandemic influenza. In addition, ill healthcare workers can transmit their illness to vulnerable patients.

• There is no need to double-glove.
• Gloves should be removed and discarded after patient care.
• Gloves should not be washed or reused.
• Hand hygiene should be done after glove removal.

• Healthcare workers should wear an isolation gown when it is anticipated that soiling of clothes or uniform with blood or other bodily fluids, including respiratory secretions, may occur. HHS states that most routine pandemic influenza patient encounters do not necessitate the use of gowns. Examples of when a gown may be needed include procedures such as intubation or when closely holding a pediatric patient.
• Isolation gowns can be disposable and made of synthetic material or reusable and made of washable cloth.
• Gowns should be the appropriate size to fully cover the areas requiring protection.
• After patient care is performed, the gown should be removed and placed in a laundry receptacle or waste container, as appropriate. Hand hygiene should follow.

• Respirators are designed to reduce an individual's exposure to airborne contaminants, such as particles, gases, or vapors. An air-purifying respirator accomplishes this by filtering the contaminant out of the air before it can be inhaled by the person wearing the respirator. A type of respirator commonly found in health-care workplaces is the filtering facepiece particulate respirator (often referred to as an "N95"). It is designed to protect against particulate hazards. Since airborne biological agents such as bacteria or viruses are particles, they can be filtered by particulate respirators. To assure a consistent level of performance, the respirator's filtering efficiency is tested and certified by NIOSH.
• In comparison, surgical masks are not designed to prevent inhalation of airborne contaminants. Their ability to filter small particles varies greatly and cannot be assured to protect healthcare workers against airborne infectious agents. Instead, their underlying purpose is to prevent contamination of a sterile field or work environment by trapping bacteria and respiratory secretions that are expelled by the wearer (i.e., protecting the patient against infection from the healthcare worker). Surgical masks are also used as a physical barrier to protect the healthcare worker from hazards such as splashes of blood or bodily fluids. When both fluid protection (e.g., blood splashes) and respiratory protection are needed, a "surgical N95" respirator can be used. This respirator is approved by FDA and certified by NIOSH.

• Particulate respirators that filter out airborne particles.
• "Gas masks" that filter out chemical gases and vapors.
• Airline respirators that use a hose/pipe to provide a flow of clean air from a remote source.
• Self-contained breathing apparatus that provide clean air from a compressed air tank worn by the user.

• Disposable or filtering facepiece respirators, where the entire respirator facepiece is comprised of filter material. It is discarded when it becomes unsuitable for further use due to excessive breathing resistance (e.g., particulate clogging the filter), unacceptable contamination/soiling, or physical damage.
• Reusable or elastomeric respirators, where the facepiece is cleaned, repaired, and reused, but the filter cartridges are discarded and replaced when they become unsuitable for further use.
• Powered air-purifying respirators, where a battery-powered blower pulls contaminated air through filters, then moves the filtered air to the wearer.

• Protection against pandemic influenza requires a comprehensive approach that includes both hygienic practices (e.g., handwashing and cough etiquette) and respiratory protection.
• Surgical masks are not considered adequate respiratory protection for airborne transmission of pandemic influenza. However, FDA-cleared surgical masks are fluid resistant and may be used for barrier protection against splashes and large droplets.
• Respiratory protection requires the use of a NIOSH-certified respirator and implementation of a comprehensive respiratory protection program that considers the following:
  • Use NIOSH-certified respirators that are N95 or higher. When both fluid protection (e.g., blood splashes) and respiratory protection are needed, use a "surgical N95" respirator that has been certified by NIOSH and cleared by the FDA.
  • Consider elastomeric respirators for essential employees who may have to decontaminate and reuse respirators in the event that there is a shortage of disposable respirators.
  • Consider powered air-purifying respirators for essential employees who may have to decontaminate and reuse respirators, wear respirators for prolonged periods of time, be exposed to high-risk procedures (e.g., bronchoscopy), or work in high-risk environments. Loose-fitting hooded powered air-purifying respirators have the additional advantage of not requiring fit testing.
• Employers, especially those whose employees are likely to be highly exposed to the flu virus (e.g., healthcare workers), should develop and implement a plan, train employees, and purchase/stockpile respiratory protection in advance for use during a pandemic since there will likely be shortages of necessary equipment during a real pandemic.

• Endotracheal intubation
• Aerosolized or nebulized medication administration
• Diagnostic sputum induction
• Bronchoscopy
• Airway suctioning
• Positive pressure ventilation via face mask (e.g., BiPAP and CPAP)
• High-frequency oscillatory ventilation

• Gown
• Respirator (or mask, when appropriate)
• Face shield or goggles
• Gloves

• Gloves
• Faceshield or goggles
• Gown
• Respirator or mask

• Healthcare facilities should ensure that sinks with warm and cold running water, plain or antimicrobial soap, disposable paper towels, and alcohol-based hand disinfectants are readily accessible in areas where patient care is provided.
• When hands are visibly dirty or contaminated with respiratory secretions, wash hands with soap (either non-antimicrobial or antimicrobial) and water.
• When washing hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use a disposable towel to turn off the faucet.
• If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations including con tact, whether gloved or ungloved, with an influenza patient.
• When decontaminating hands with an alcohol-based hand rub, apply product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's recommendations regarding the amount of product to use.
• Always use hand hygiene after removing gloves and other PPE.
• Healthcare facility leaders should make adherence to hand hygiene an institutional priority.

• Avoid touching their eyes, nose, or mouth with contaminated hands (gloved or ungloved) to avoid self-inoculation with the pandemic influenza virus.
• Avoid contaminating environmental surfaces that are not directly related to patient care such as light switches and doorknobs.

• Healthcare workers, including housekeeping staff, should wear gloves when handling pandemic influenza patients' trays, dishes, and utensils.
• The healthcare facility should wash reusable dishes and utensils in a dishwasher at the recommended water temperature.
• If disposable dishes and utensils are used, these may be discarded with other general waste.

• Healthcare workers should place soiled linen directly into a laundry bag in the patient's room. The linen should be contained in a manner that prevents the bag from opening during transport and while in the soiled linen holding area.
• Healthcare workers should wear gloves and gowns when directly handling soiled linen and laundry (e.g., bedding, towels, and personal clothing), as per standard precautions. There should be no shaking or handling of soiled linen and laundry in a manner that might create an opportunity for disease transmission or contamination of the environment.
• Healthcare workers should wear gloves when transporting bagged linen and laundry.
• Healthcare workers should perform hand hygiene after removing gloves that have been in contact with soiled linen and laundry.
• The healthcare facility should ensure that linens and laundry are washed and dried in accordance with infection control standards and procedures.

• Healthcare workers should wear gloves when handling and transporting used patient care equipment.
• Healthcare workers should wipe heavily soiled equipment with a U.S. Environmental Protection Agency (EPA)-approved hospital disinfectant before removing it from the patient's room and follow current recommendations for cleaning and disinfection or sterilization of reusable patient care equipment.
• Healthcare workers should wipe external surfaces of portable equipment (e.g., for performing x-rays and other procedures) in the patient's room with an EPA-approved hospital disinfectant upon removal from the patient's room.

• Wear gloves in accordance with facility policies for environmental cleaning. 4
• Wear a surgical mask in accordance with droplet precautions. 4 Use a respirator when airborne precautions are warranted by the circumstances.
• Gowns are usually not necessary for routine cleaning of an influenza patient's room. 4 However, a gown must be worn when cleaning a patient's room if soiling of the employee's clothes or uniform with blood or other potentially infectious materials may occur.
• Wear face and eye protection if cleaning within 3 feet of a coughing patient.
• Keep areas within 3 feet of the patient free of unnecessary supplies and equipment to facilitate daily cleaning. 4
• Use any EPA-registered hospital detergent-disinfectant. 4
• Give special attention to frequently touched surfaces (e.g., bedrails, bedside and over-bed tables, TV controls, call buttons, telephones, lavatory surfaces including safety/pull-up bars, doorknobs, commodes, and ventilator surfaces) in addition to floors and other horizontal surfaces. 4

• Follow standard facility procedures for post-discharge cleaning of an isolation room.
• Clean and disinfect all surfaces that were in contact with the patient or might have become contaminated during patient care.

• Contain and dispose of contaminated medical waste in accordance with facility procedures and/or local or state regulations for handling and disposal of medical waste, including used needles and other sharps, and non-medical waste.
• Discard used patient care supplies that are not likely to be contaminated (e.g., paper wrappers) as routine waste.
• Healthcare workers should wear disposable gloves when handling waste and should practice hand hygiene after removal of gloves.

1. HHS. Centers for Disease Control and Prevention, Atlanta, Georgia. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17:53-80. [Back]
2. Garner JS, Guideline for isolation precautions in hospitals. Part I. Evolution of isolation practices, Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996; 24:24-52. [Back]
3. HHS. Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health-Care Settings. MMWR. October 25, 2002/51 (RR16); 1-44. [Back]
4. HHS. 2005. Pandemic Influenza Plan, Supplement 4. U.S. Department of Health and Human Services. Last accessed February 20, 2005: www.hhs.gov/pandemicflu/plan/sup4.html. [Back]
5. CDC, Interim Recommendations for Infection Control in Healthcare Facilities Caring for Patients with Known or Suspected Avian Influenza, May 21, 2004, http://www.cdc.gov/flu/avian/professional/infect-control.htm. [Back]
6. HHS. CDC, Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2 Supplement I: Infection Control in Healthcare, Home, and Community Settings, III. Infection Control in Healthcare Facilities May 3, 2005 accessed 4/11/2006 at http://www.cdc.gov/ncidod/sars/guidance/I/healthcare.htm. [Back]
7. HHS. Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Health-Care-Associated Pneumonia. MMWR, March 26, 2004/53(RR-03);1-36. [Back]
8. HHS. Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings during an Influenza Pandemic. October 2006. Accessed 3/7/07 at www.pandemicflu.gov/plan/healthcare/maskguidancehc.html. [Back]
9. Kellerman SE, Saiman L, San Gabriel P, Besser R, Jarvis WR. Observational study of the use of infection control interventions for Mycobacterium tuberculosis in pediatric facilities. Pediatr Infect Dis J. 2001 Jun;20(6):566-70. [Back]
10. Ofner-Agostini, et al., Cluster of Cases of Severe Acute Respiratory Syndrome Among Toronto Healthcare Workers After Implementation of Infection Control Precautions: A Case Series Infect Control Hosp Epidemiol 2006; 27: 473-478. [Back]
11. HHS. Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, TB Respiratory Protection Program in Health Care Facilities Administrator's Guide, September 1999. [Back]
12. Imai, et al., SARS risk perceptions in healthcare workers, Japan. Emerg Infect Disease 2005; 11: 404–410. [Back]
13. Gershon RRM, et al. Compliance with universal precautions among health care workers at three regional hospitals. Am J Infect Control 1995;23:225–36. [Back]
14. DeJoy DM, et al. The influence of employee, job/task, and organizational factors on adherence to universal precautions among nurses. Int J Ind Ergon 1995;16:43-55. [Back]
15. DeJoy DM, et al. Behavioral-diagnostic analysis of compliance with universal precautions among nurses. J Occup Health Psychol 2000;5:127-41. [Back]
16. Gershon RR, et al. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control 2000;28: 211-21. [Back]
17. SARS Key Learnings from the Perspective of University Health Network, Notes for the Campbell Commission, Available at: http://www.uhn.ca/uhn/corporate/community/docs/campbell_presentation_100103.pdf. [Back]
18. HHS. Pandemic Influenza Plan, Part 1, Strategic Plan, November 2005 Available at http://www.hhs.gov/pandemicflu/plan/part1.html. [Back]
19. Loutfy, et al., Hospital Preparedness and SARS, Emerg Inf Dis, Vol. 10, No. 5, May 2004. p 771-776. [Back]
20. Centers for Disease Control and Prevention, Instructions to Estimate the Potential Impact of the Next Influenza Pandemic Upon Locale Y, Available at http://www.cdc.gov/flu/pandemic/impactestimate.htm; accessed 6/19/06. [Back]
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• Develop planning and decision making strategies for responding to pandemic influenza.
  • Define roles for disaster response, including responsibility for coordination of a pandemic plan. For example, identify the individuals within your organization who will be responsible for coordinating communications, integrating public health recommendations, establishing security, and developing a written plan.
  • Note that individual circumstances may affect specific facilities (e.g., rural vs. urban medical facilities, hospital vs. pre-hospital and general practices vs. specialized medical facilities).
• Understand how to access state and federal information and supplies, and to ensure communication with local, state, and federal health and security agencies. Identify supply chain issues and develop alternatives as needed (e.g., overseas sources).
• Develop written plans that address disease surveillance, isolation and quarantine practices, hospital capacity criteria, hospital communication, staff education and training, triage, clinical evaluation and diagnosis, security, facility access, facility infrastructure (e.g., isolation rooms), occupational health for employees, use and administration of vaccines and antiviral drugs, facility surge capacity (e.g., durable and consumable supplies), supply chains (purchase, distribution and transportation of supplies), access to critical inventory supplies, and mortuary issues (e.g., storage capacity). This is not a comprehensive list. Planning should be tailored to the specific facility and community.
• Work with local, state and national emergency planning committees to integrate with community, state and national pandemic plans and training.
• Participate in pandemic influenza response exercises and drills on local and, if possible, state and federal levels. Incorporate lessons learned into the pandemic disaster response plans.

• Heighten institutional surveillance of patients and facility/clinic staff for influenza-like illness.
• Prepare to activate institutional pandemic influenza plans, as necessary.
• Establish communications with local, state, and federal agencies regarding surveillance issues and recommendations.

• Activate institutional pandemic influenza plans to protect staff and patients.
• Heighten institutional surveillance of patients and facility/clinic staff for influenza-like illness.
• Implement surge capacity plans to sustain healthcare delivery.
• Identify and isolate potential pandemic influenza patients.
• Implement infection control practices to prevent influenza transmission and monitor staff and patients for nosocomial transmission.
• Ensure rapid and frequent communication within healthcare facilities and between health-care facilities, state health departments, and the federal government.
• Ensure that there is a process for reporting influenza cases and fatalities.

• Continue institutional surveillance of patients and facility/clinic staff for influenza-like illness.
• Return to normal facility operations as soon as possible.
• Review pandemic influenza plan based on experience during the first pandemic wave. Incorporate lessons learned into preparation for subsequent pandemic waves.
• Identify and anticipate resource and supply chain issues.
• Continue to emphasize communication within healthcare facilities and between healthcare facilities, state health departments, and the federal government to identify subsequent pandemic waves.

• Department of Health and Human Services Pandemic Influenza Plan, Supplement 10, available at http://www.hhs.gov/pandemicflu/plan/sup10.html#I.
• Pandemicflu.gov "Risk Communication" web-site, available at http://www.pandemicflu.gov/news/rcommunication.html.

• Department of Health and Human Services
  http://www.pandemicflu.gov/outbreaks/#ussurv.
• Centers for Disease Control and Prevention
  http://www.cdc.gov/flu/weekly/fluactivity.htm.
• World Health Organization
  http://www.who.int/csr/disease/influenza/influenzanetwork/en/index.html.

• Supplement 11 of the HHS Pandemic Influenza Plan at www.hhs.gov/pandemicflu/plan/sup11.htm.
• Center for the Study of Traumatic Stress. Mental Health and Behavioral Guidelines for Response to Pandemic Influenza. http://www.usuhs.mil/psy/CSTSPandemicAvianInfluenza.pdf

• Disposable N95 respirators, surgical masks
• Face shields (disposable or reusable)
• Gowns
• Gloves

1. HSC. 2006. National Strategy for Pandemic Influenza Implementation Plan, Homeland Security Council Chapter 6, May. [Back]
2. Zinkovich L., D. Malvey, et al. 2005. Bioterror events: preemptive strategies for healthcare executives. Hosp Top, 83(3):9-15. [Back]
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7. Niska R., C. Burt. 2005. Bioterrorism and mass casualty preparedness in hospitals: United States, 2003. National Center for Health Statistics, Hyattsville, MD. Adv Data, no. 364. [Back]
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10. Hawryluck L., S. Lapindky, T. Steward. 2005. Clinical review: SARS – lessons in disaster management. Crit Care 9(4): 384-389. August. [Back]
11. HHS. 2005. Pandemic Influenza Plan, Supplement 11, Workforce Support: Psychological Considerations and Information Needs. U.S. Department of Health and Human Services. November. [Back]
12. Johnson M., E. Bone, G. Predy. 2005. Taking care of the sick and scared. Can J Public Health 96(6): 412-414. November-December. [Back]
13. Booth C., T. Stewart. 2005. Severe acute respiratory syndrome and critical care medicine: The Toronto experience. Crit Care Med 33(1) (suppl.): S53-S60. [Back]
14. Booth C., T. Stewart. 2003. Communication in the Toronto critical care community: important lessons learned during SARS. Crit Care 7(6): 405-406. December. [Back]
15. HHS. 2005. Pandemic Influenza Plan, Supplement 8, Disease Control and Prevention. U.S. Department of Health and Human Services. November. [Back]
16. U.S. Department of State. United States Pursues Criminal Charges in Bird Flu Drug Fraud. http://usinfo.state.gov/gi/Archive/2006/Jan/23-183730.html 23 January 2006. Last accessed January 18, 2007. [Back]
17. HHS. 2005. Pandemic Influenza Plan, Supplement 1, Pandemic Influenza Surveillance. U.S. Department of Health and Human Services. November. [Back]
18. Gibbs W., C. Soares. 2005. Preparing for a pandemic. Sci Am. 45-54. November. [Back]
19. McDonald L.C., Simor A.E., et al. 2004 SARS in Healthcare Facilities, Toronto and Tiwan. Emerg Infect Dis. 10(5): 777-781. May. [Back]
20. Maunder R., J. Hunter, et al. 2003. The Immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Can Med Assoc J. 168(10): 1245-1251. May. [Back]
21. Ovadia K., I. Gazit, et al. 2005. Better late than never: a re-examination of ethical dilemmas in coping with severe acute respiratory syndrome. J Hosp Infect 61: 75-79. [Back]
22. Reissman D., P. Watson, et al. 2006. Pandemic influenza preparedness: adaptive responses to an evolving challenge. Journal of Homeland Security and Emergency Management, 3(2):1-26. [Back]
23. CSTS. Mental Health and Behavioral Guidelines for Response o Pandemic Influenza. http://www.usuhs.mil/psy/CSTSPandemicAvianInfluenza.pdf. Last accessed January 18, 2007. [Back]
24. U.S. Department of Veterans Affairs. Psychological First Aid Manual. http://www.ncptsd.va.gov/pfa/PFA.html. Last accessed January 18, 2007. [Back]
25. Rambaldini G., W. Kumanan, et al. 2005. The impact of Severe Acute Respiratory Syndrome on medical house staff. J. Gen Intern Med 20:318-385. [Back]
26. Chen C.S., H.Y. Wu., et al. 2005. Psychological distress of nurses in Taiwan who worked during the outbreak of SARS. Psychiatr Serv 56(1): 76-9. [Back]
27. HHS. 2005. Pandemic Influenza Plan, Supplement 4, Infection Control. U.S. Department of Health and Human Services. November. [Back]
28. Higgins W., C. Wainright, et al. 2004. Assessing hospital preparedness using an instrument based on the Mass Casualty Disaster Plan Checklist: Results of a statewide survey. Am J Infect Control 32(6): 327-332. [Back]
29. HHS. 2006. Pandemic Planning Update A Report from Secretary Michael O. Leavitt. Department of Health and Human Services. March 13. [Back]
30. JCAHO. 2003. Health Care at the Crossroads: strategies for creating and sustaining community-wide emergency preparedness systems. Joint Commission on Accreditation of Healthcare Organizations. [Back]
31. News Release. May 4, 2006 HHS Awards Contracts Totaling More than $1 Billion to Develop Cell-Based Influenza Vaccine. http://www.hhs.gov/news/press/2006pres/20060504.html. Last accessed January 18, 2007. [Back]
32. HHS. 2005. Pandemic Influenza Plan, Supplement 6, Vaccine Distribution and Use. U.S. Department of Health and Human Services. November. [Back]
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36. WHO. 2006. Avian Influenza, including Influenza A (H5N1), in Humans: WHO Interim Infection Control Guideline for Health Care Facilities. World Health Organization. February 9. Last accessed on January 18, 2007 at http://www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1/en/. [Back]
37. HHS. 2005. Pandemic Influenza Plan, Supplement 7, Antiviral Drug Distribution and Use. U.S. Department of Health and Human Services. November. [Back]
38. Cinti S. 2005. Pandemic influenza: are we ready? Disaster Manag Response 3:61067. [Back]
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1. OSHA. Occupational Safety and Health Act of 1970 (OSH Act). [Back]
2. 29 U.S.C. 654(a)(1). [Back]

• Procedures for selecting appropriate respirators for use in the workplace.
• Fit testing tight-fitting respirators.
• Cleaning, disinfecting, storing, inspecting, repairing, removing from service or discarding, and otherwise maintaining respirators. Also, you must establish schedules for these elements.
• Ensuring adequate air supply, quantity, and flow of breathing air for atmosphere supplying respirators.
• Provisions for medical evaluation of employees who must use respirators.
• Training employees in the proper use of respirators (including putting them on and removing them), the limitations on their use, and their maintenance.
• Regularly evaluating the effectiveness of the program.

• Prior to initial use.
• Whenever an employee switches to a different tight-fitting facepiece respirator (for example, a different size, make, model, or style).
• At least annually.

• Reported by the respirator user.
• Observed by the employer, a physician or other licensed healthcare professional, the supervisor, or the program administrator.
• Physical changes in the employee that might affect the facepiece-to-face seal could include, for example, an obvious change in body weight, facial scarring, dental work, or cosmetic surgery.

• Facial hair
• Facial scars
• Jewelry or headgear
• Missing dentures
• Corrective glasses or goggles or other PPE such as:
  • Face shields
  • Protective clothing
  • Helmets
  • Eyeglass insert or spectacle kits

• Does not interfere with the face-to-facepiece seal.
• Does not distort the employee's vision.
• Does not cause physical harm to the employee (e.g., if the eyeglass insert did not fit properly so that the tight fit of the respirator caused the insert to press against his or her forehead, eyes, or temples).

• Covers the respirator inlets (cartridges, canisters, or seals)
• Gently inhales, and
• Holds breath for 10 seconds.

• Covers the respirator exhalation valve(s); and
• Gently exhales.

• Cleaning and disinfection procedures
• Proper storage
• Regular inspections
• Repair methods

• Disassembly of components
• Cleaning and disinfecting
• Rinsing, drying, and reassembly
• Inspection

• Protects them from contamination, dust, sunlight, extreme temperatures, excessive moisture, damaging chemicals, or other destructive conditions.
• Prevents the facepiece or valves from becoming deformed.
• Follows all storage precautions issued by the respirator manufacturer.

• Kept accessible to the work area, but not in an area that may itself become involved in an emergency and become contaminated or inaccessible.
• Stored in a compartment or cover (e.g., on a fire truck) that is clearly identified as containing emergency equipment.

1. Why the respirator is necessary and how improper fit, usage, and maintenance can make the respirator ineffective.
   Training must address the identification of hazards, the extent of employee exposure to those hazards, and the potential health effects of exposure. The training that is required under the Hazard Communication standard (29 CFR 1910.1200) can satisfy this requirement for chemical hazards. Employees must understand that proper fit, usage, and maintenance of respirators is critical to ensure that they can perform their protective function.
2. The limitations and capabilities of the selected respirator.
   Training must cover how the respirator operates. Included must be an explanation of how the respirator provides protection by filtering the air, absorbing the gas or vapor, or by supplying a clean source of air. Limitations on the use of the equipment, such as prohibitions against using an air-purifying respirator in an immediately dangerous to life and health atmosphere, and why not, must also be explained.
3. How to inspect, put on and remove, and check the seals of the respirator.
   Employers must train employees how to recognize problems that may decrease the effectiveness of the respirator and what steps to follow if a problem is detected, such as the person to whom problems should be reported and where replacement equipment can be obtained if needed. If specialized personnel conduct inspections, individual respirator wearers only need to be taught about the portions of the inspection process that are their responsibility. Training must also cover how to properly put on and remove the respirator to ensure that respirator fit in the workplace is as close as possible to the fit obtained during fit testing.
4. The proper respirator maintenance and storage procedures.
   The extent of training required may vary according to workplace conditions. If employees are individually responsible for storing and maintaining respirators, detailed training may be necessary. If specialized personnel perform these functions, employees only need to be informed of the maintenance and storage procedures.
5. The general requirements of the Respiratory Protection standard.
   Employers must ensure that employees are aware, in general, of the employer's obligations under the standard. This discussion need not focus on the standard's provisions but could, for example, simply inform employees that employers are obligated to develop a written program, properly select respirators, evaluate respirator use, correct deficiencies in respirator use, conduct medical evaluations, provide for the maintenance, storage and cleaning of respirators, and retain and provide access to specific records.

• Changes in the workplace or the type of respirator make previous training obsolete.
• The knowledge and skill necessary to use the respirator properly has not been retained by the employee.
• Any other situation arises in which retraining appears necessary to ensure safe respirator use.

• a matrix that defines parameters that will be the critical determinants of the level of risk at DHMC
• a summary of the elements of the baseline state of readiness that should be maintained at all times
• a summary of the ways in which our surveillance, prevention and control activities may need to change at each level of increasing risk to DHMC
• an appendix that includes standard operating procedures for the management of patients who have suspected ERI as outpatients, as inpatients, and for resuscitation of these patients.

• To prevent cases of vaccine-preventable contagious respiratory infection (e.g., influenza) at DHMC and in the community.
• To promote early detection of initial cases of contagious respiratory infection (including, but not limited to influenza, SARS).
• To prevent nosocomial spread of contagious respiratory infections.
• To create systems for real-time data collection flexible enough to be adapted for use in an epidemic setting.

• For patients and the public
  • Nursing will carry out standing orders for all eligible patients to be offered and receive influenza vaccine in all clinics and prior to discharge from all inpatient units.
  • DHMC will continue to collaborate with other community health organizations to hold public clinics to provide influenza vaccine to all eligible community members of any age.
  • Public Affairs, with input from the Readiness Committee, will develop educational and promotional materials to promote availability and desirability of influenza vaccine for all.
  • The administering provider of flu vaccine in the inpatient and outpatient setting will document administration of influenza vaccine in CIS.
• For staff, volunteers, and students
  • Administrative, educational, and clinical leaders will promote maximum participation of staff, volunteers, and students in influenza vaccine program.
  • Occupational Medicine will provide multiple opportunities for staff, volunteers, and students to receive influenza vaccine conveniently and efficiently.
  • Occupational Medicine will present regular updates of physician compliance with flu vaccine by section for review by Board of Governors.
  • DHMC will report flu vaccine rates among
  • direct care providers on public reporting web-site.

• The Security Office will develop a plan and a timeline for implementing a policy that enables them to control access to the medical center through the use of mandatory ID badges for all staff, volunteers, students, vendors, and other people coming to DHMC to work, and a plan to lock down certain entrances and exits, and to monitor use of others, if necessary.

• For patients
  • Receptionists will screen all outpatients at the time of registration at selected DHMC clinics, the ED, and the Dartmouth College Health Service with the following question: Do you have a new cough that has developed over the last 10 days?, and will:
    • Provide patients who have a new cough with a surgical mask and/or tissues.
    • Document data at time of screening and transmit clinic-specific data to Infection Control each week for review and analysis of trends.
  • Clinical staff at these clinics will:
    • Evaluate patients who have a new cough or fever.
    • Place all patients who have fever and a new cough on droplet precautions, pending further evaluation.
  • The admitting office staff will screen all patients at the time of admission for "fever and cough" and will:
    • Admit patients with fever and cough to a private room with droplet precautions.
    • Document data at time of screening and transmit inpatient admitting diagnoses to Infection Control daily for review of appropriate use of precautions for inpatients.
• For staff, volunteers, and students
  • Receptionists will screen all staff, volunteers, or students who present to Occupational Medicine clinic with the following question: Do you have a new cough that has developed over the last 10 days?, and will:
    • Provide patients who have a new cough with a surgical mask and/or tissues.
    • Document data at time of screening and transmit clinic-specific data to Infection Control each week for review and analysis of trends.
  • Clinical staff in Occupational Medicine clinic will:
    • Evaluate patients who have a new cough or fever.
    • Place all patients who have fever and a new cough on droplet precautions, pending further evaluation.
  • Occupational Medicine staff, clinical and administrative leaders will advise staff, volunteers and students who have fever and a new cough not to come to work.
  • Occupational Medicine will:
    • Screen staff, volunteers, and students who report pneumonia or respiratory infection to identify possible clusters of pneumonia or respiratory infection in healthcare providers
    • Report possible clusters to Infection Control.
• For visitors, vendors, registrants at conferences
  • Public Affairs will maintain "Ask for a Mask" signs at all entrances, and at all meeting rooms, to encourage all persons entering DHMC to self-screen (rotating the posters periodically to maintain impact).
  • Via posters, ask persons who have new cough to wear a surgical mask or use tissues to cover their mouth and nose when coughing, and to use good hand hygiene during the time they need to be at DHMC.
  • All staff will advise persons who have fever and cough to defer visiting DHMC until their illness has resolved.
• Monitoring surveillance data
  • The Infection Control Unit will monitor national, regional, and local data related to ERI and report changing trends to the Readiness Committee on a regular basis.

• All staff, volunteers, and students will use Droplet Precautions (private room and surgical mask within 3 feet of patient) for all contact with any outpatient who has a new cough and fever, until a diagnosis of a non-contagious respiratory illness, or an infection requiring a higher level of precautions, is made.
• All staff, volunteers, and students will use Droplet Precautions (private room and surgical mask within 3 feet of patient) for all contact with any patient being admitted to the hospital who has a new cough and fever until a diagnosis of a non-contagious respiratory illness, or an infection requiring a higher level of precautions, is made.
• Clinic and inpatient staff will use a visible doorway "precautions sign" system to allow persons entering the room to know what type of protective equipment is needed.
• Clinic Administrative services and Housekeeping will maintain adequate supplies at all times of surgical masks, waterless hand rub, and tissues throughout public areas, clinic waiting rooms, and meeting rooms. Clinic and inpatient unit staff will maintain these supplies in clinical areas.
• The Safety Office will identify key areas throughout the hospital which need to maintain core groups of N95 respirator fit-tested personnel.
  • Each director is responsible for maintaining the appropriate number of trained and fit-tested staff
• The Safety Office will ensure that an adequate number of PAPRs are maintained for use by personnel who cannot use N95 respirators.
• Engineering will maintain negative pressure-capable rooms on 3 West.
  • Nursing will develop plans for moving patients out of these rooms on 3 West if needed.

• Public Affairs will develop a sustainable and effective plan for communication and promotion of messages relating to ERI to internal and external audiences.
• Public Affairs and Communications will coordinate with the Emergency Preparedness Committee to develop an internal communication plan to allow immediate access to predefined groups of people, including "on call" staff, via e-mail, Intranet, paging system, telephone.
• The Center for Continuing Education in the Health Sciences will develop a sustainable plan to orient and educate staff regarding basic readiness activities at DHMC, and a strategy for "just-in-time" educational activities to provide timely information to providers in the event of ERI.

• The Readiness Committee will meet approximately once a month.
• The Readiness Committee will designate an Incident Command core team including senior administration, infection control, ACOS, communications, nursing, safety, engineering, security, College Health Service with 7-day a week availability to respond to a potential outbreak of contagious respiratory infection.
• The Infection Control Unit will monitor the Health Alert Network and other communications from public health officials to review changes in recommendations from NH DHHS/CDC about screening criteria and will communicate changes to clinicians via some combination of e-mail, Intranet, or radiographic or laboratory reporting.

• The Readiness Committee will consider the need to activate the policy on requiring staff, volunteers, students, and vendors to wear identification while in the medical center.

• "Ask for a Mask" signs will be placed at all entrances, and in all meeting rooms, which may be modified to include specific risk factors for a specific ERI, to encourage all persons entering DHMC to self-screen.
  • Persons who self-identify as at risk for the designated infection are instructed to don a surgical mask and may be asked to go to a designated location for clinical evaluation.
• Receptionists in selected areas (which may expand) will continue to screen all patients at registration for new cough, and additional questions may be added if appropriate. Receptionists will:
  • Provide patients who have a new cough who have specific risk factors for the targeted infection with a surgical mask and ask clinical staff to place them immediately in a private exam room.
  • Provide patients who have a new cough but no specific risk factors for the targeted infection with a surgical mask and/or tissues.
• Clinical staff will evaluate:
  • Patients who answer "yes" to new cough and specific risk factors for fever and other symptoms, using N95 masks, gowns, gloves and eye protection.
  • Patients who answer yes to new cough but do not have specific risk factors, using droplet precautions.
• Clinicians who suspect, after initial clinical evaluation that a patient may have an ERI should immediately consult with the Infectious Disease Service and the Infection Control Unit, who will involve the state health department as appropriate. (IF A PATIENT IS DETERMINED TO BE A SUSPECT CASE OF ERI,GO TO LEVEL: "CONTROLLED ORANGE")
• No patient can be admitted or accepted in transfer to DHMC with a suspected diagnosis of the ERI in question, without the approval of the Infectious Disease Service.
• Staff, volunteers, and students traveling to designated high risk areas must register with Occupational Medicine upon return and report any symptoms of fever or cough that occur during a specified time period. Occupational Medicine will maintain a list of people under surveillance for this reason.

• Airborne, droplet, and contact precautions are required for all contact with any outpatient who has screened as a possible ERI case, until an alternate diagnosis is made.
• Droplet precautions are required for all contact with any outpatient who has a new cough and fever, but no risk factors for the ERI, until a diagnosis of a non-contagious respiratory illness, or an infection requiring a higher level of precautions, is made.
• Any patient who has screened as a possible ERI case and requires admission to DHMC, must be admitted to a negative pressure room on 3 West, where airborne and contact precautions are required for all contact. (IF A PATIENT IS DETERMINED TO BE A SUSPECT CASE OF ERI, GO TO LEVEL: "CONTROLLED ORANGE").

• At each committee meeting, the Readiness Committee will review the need for communication with, or educational programs for staff, volunteers, and students, and the public.

• The Readiness Committee meets once or twice a month, depending on the stability of the situation.

• Review need to require staff, volunteers, students, and vendors to wear ID badges at all times.

• Expand screening and triage of patients and employees to all clinics, with regular review of need to modify or add specific risk factors.
• Continued use of posters to promote screening visitors and vendors.

• No changes

• No changes

• The Readiness Committee meets at least once a week to review surveillance data and new recommendations from DHHS/CDC.
• Evaluate the availability and appropriateness of disease-specific vaccine or preventive treatment.

• Limit visitors and admissions to 3 West.
• Review need to restrict vendors, visitors, conferences.
• Require staff, volunteers, students, vendors, and other people coming to DHMC to work to wear their badges/identification at all times.

• Modified "Ask for a Mask" signs remain at all entrances, and at all meeting rooms, which include specific risk factors for the targeted infection, to encourage all persons entering DHMC to self-screen.
  • A knowledgeable staff member may need to be present at all entrances to assist people with self-screening, answer questions, and direct them to evaluation centers if needed.
  • Screening questions for patients and employees at registration, admission will be reviewed and modified as needed at each Readiness Committee meeting.
  • Staff, volunteers, and students who have had contact with suspected patients must register with Occupational Medicine and be screened daily for fever or respiratory symptoms.
  • Surveillance data will be transmitted to Infection Control for review daily.

• No changes

• Regular updates to all staff via Intranet as determined by the Readiness Committee.

• Readiness Committee will meet daily to review situation and strategies.
• Nursing and ACOS will review plans for moving non-epidemic patients out of negative pressure-capable rooms on 3 West; Engineering will review plan to add HEPA filters and negative pressure to additional rooms on 3 West and ensure that the plan could be operationalized within 4 hours if needed.
• Infection Control will notify microbiology laboratory director of relevant information.

• All entrances to medical center will be locked except the Main Entrance, the entrance from Parking Garage, and the Emergency Department entrance.
• Security guards will be stationed at open entrances.
• Entry into facility will be restricted to the following:
  • Staff, and students with valid ID
  • Patients with appointments
  • A single adult accompanying a patient
  • A single parent of hospitalized child
• Those allowed into the facility must be screened for fever or cough (see Surveillance, screening and triage below) and have their temperature taken and if cleared, given something to indicate that they have been cleared to enter the facility (e.g., a sticker, a card, a stamp on their hand).
• Activities of Food Court eateries and shops, hair salon, optical shop, etc. will be suspended.
• Activities of vendors, volunteer activities, continuing education programs, except those related to the epidemic disease will be suspended.
• There will be some degree of suspension of elective surgeries, elective admissions, elective outpatient appointments as determined by the Readiness Committee.
• There will be some level of suspension of medical student rotations, construction as determined by the Readiness Committee.

• Patients calling for same day appointments will be screened for new cough developing over the last 10 days.
  • Patients who answer yes will be phone triaged to a clinician who can do further screening for epidemic infection risk factors and determine the need for the patient to be evaluated in person.
• Patients being called with appointment reminders will be screened for new cough and phone triaged to a clinician for further screening prior to coming to DHMC.
• All people entering DHMC will be actively screened by trained staff for cough or fever at open entrances
  • Patients and visitors who are identified to have fever and/or cough will be instructed to don a surgical mask, use waterless handrub, and go to a designated evaluation location (NB: risk factors at this alert level may be simply living in the Upper Valley, or having been at DHMC).
  • Employees who have fever and/or cough will be considered possible cases:
    • If at home, they should call Occupational Medicine for evaluation prior to coming to work.
    • If at work, they should call Occupational Medicine and be instructed regarding the need for evaluation.
    • Occupational Medicine will develop a tool to screen employees regarding need for evaluation, need for home isolation, etc.
  • After evaluation, no patient or employee who has fever or cough will be allowed to remain at DHMC unless the person requires hospitalization.
    • The name and phone number/address of all patients or employees sent home with suspected epidemic infection should be recorded and reported to the NH DHHS.
• Occupational Medicine will continue to maintain a log of which employees have contact with epidemic patients, whether there are unprotected exposures, and the employee's health and work status daily.

• An N95 mask and contact precautions are required for all HCWs having contact with any outpatient who has fever and/or a new cough, until an alternate diagnosis is made. (This includes staff who conduct screening at DHMC entrances.)
• Adequate supplies of personal protective equipment, waterless hand rub, tissues will be maintained throughout the hospital by Housekeeping and Clinic Administrative Services, as well as clinical staff.
• Everyone providing patient care will be N95 respirator fit-tested.

• Daily or more frequent updates to staff and the public/press will be provided as determined by the Readiness Committee.

• The Readiness Committee will meet twice daily to review infection control surveillance data, clinic operations (i.e., number of screening evaluations being done) and adequacy of new controls and revise alert level as needed.
• The Readiness Committee will reassess daily the need to create special epidemic inpatient unit off site (e.g., Armory).
• Staff may be redeployed from areas where clinical activities have been suspended or limited to screening, infection control, Occupational Medicine, epidemic patient care and other areas of need, as determined by Readiness Committee in collaboration with hospital leaders.

• All entrances to medical center will be locked except one entrance designated for employees and Emergency Dept entrance.
• Security guards will be stationed at open entrances.
• Entry into facility will be restricted to the following:
  • Employee with valid ID
  • Patient arriving by ambulance [a parent may remain with a hospitalized child but cannot come and go from the medical center]
  • Patients who must receive regular, life-sustaining treatments at DHMC (e.g., dialysis patients, transfusion-dependent patients)
• Those allowed into the facility must be screened for cough and other criteria (as outlined in ORANGE) and have their temperature taken and if cleared, given something to indicate that they have been cleared to enter the facility.
• Suspension of elective surgeries, elective admissions, elective outpatient appointments, non-emergency transfers as determined by the Readiness Committee.
• Suspension of on-site student rotations, construction activities.
  • Possible redeployment of clinical students to areas of need.

• Required daily for all persons entering facility (see ORANGE).

• All staff will wear surgical masks and use frequent hand hygiene at all times while in the facility.

• There will be daily or more frequent updates to staff and the public/press as determined by the Readiness Committee.

• The Readiness Committee will meet twice daily to review situation.
• The Readiness Committee will reassess daily the need to create special epidemic inpatient unit off site (e.g., Armory).
• Staff may be redeployed from areas where clinical activities have been suspended or limited to screening, infection control, Occupational Medicine, epidemic patient care and other areas of need, as determined by Readiness Committee in collaboration with hospital leaders.

• Minimize Health Care Workers (HCW) contact with the patient.
• Protect HCWs during contact with patient.
• Minimize opportunities for exposure to other patients or visitors.

1. The receptionist should give the patient a mask to put on covering their nose and mouth and immediately inform the nurse who will immediately place the patient in a private exam room, the door to the exam room must be kept closed. We want to minimize the amount of time that the patient is in the waiting area or other common areas.
2. Personnel Protective Equipment (PPE) is required for anyone going in the room to see the patient. This includes gown, gloves, goggles and N95 mask or PAPR hood. N95 masks and the PAPR hoods will be available from the Safety Office (ext. 57233) during the day or the ACOS after hours.
3. The health care provider who was scheduled to see the patient will evaluate them to confirm that they have a fever >38, respiratory symptoms and risk factors for ERI. If the provider confirms this information s/he should contact the Infectious Disease physician by calling the DHMC operator and asking for the ID physician on call.
4. The ID physician will consult with the patient's provider to confirm the suspect case and plan further evaluation. They will also notify the Infection Control Team and the NH Department of Health. If possible, a disposition decision should be made at this time.
5. If the patient is in a clinic without a negative pressure room and is considered to be a suspect case of ERI and needs further evaluation, including lab work and/or X-rays, to determine the need for hospital admission they will be moved as soon as possible to the negative air pressure room in the Emergency Department. The clinic nurse caring for the patient must call the ED (ext 57000) and notify them of this. When the patient is moved to the ED, they should be wearing a surgical mask. The patient should be taken to the ED via a route that avoids crowded public areas. The clinic nurse who has been caring for the patient will transport the patient to the ED and should continue to wear PPE.
   If the patient is no longer considered to be a suspect case they may continue with their appointment as scheduled. People no longer need to follow contact and airborne isolation, only appropriate Standard Precautions.
6. The patient will remain in the negative pressure room in the ED until a decision regarding admission is made. The patient will only leave for urgent medically necessary tests that can not be done in the negative pressure room. If the patient needs to leave the ED, the charge nurse is responsible for notifying the department that they will be going to that the patient requires airborne and contact precautions. The PPE will go with the patient when they leave the ED. Employees who have contact with the patient should be kept to a minimum.
7. If the patient is stable and does not need admission the provider should coordinate appropriate medical follow-up and surveillance from the NH Department of Health prior to discharge from the clinic or ED.
8. If the patient requires admission to DHMC the Infectious Disease physician will activate the ERI plan and notify Admitting of the need to admit the patient to a negative pressure room. N95 masks and PAPR hoods will be sent with the patient. The patient will travel from the clinic or ED to the unit wearing a surgical mask via a route that avoids crowded public areas. The nurse who has been caring for the patient will transport the patient to the inpatient room and should continue to wear PPE during transport.

• Minimize Health Care Workers (HCW) contact with the patient.
• Protect HCWs during contact with patient.
• Minimize opportunities for exposure to other patients or visitors.

• Patient will be admitted only when medically necessary.
• Patients will not be admitted solely for the purpose of isolation.
• The Infectious Disease service must approve all admissions for ERI and is responsible for activating the ERI plan in collaboration with Infection Control.

• Planning and activity will begin to prepare room 303 as a potential intensive care location. Engineering will install special ventilation unit to create negative pressure (Engineering Services Policy 6.207b; Temporary Negative Pressure Rooms).

• 3W- Pod 1 now restricted to only ERI patients. ACOS, Admitting, and nursing directors will make arrangements to move the non-ERI patients on Pod 1 to another area of the hospital.
• Engineering will install special ventilation units to create negative pressure in rooms 327, 328, and 329. Contact State of NH to get more portable HEPA filter units.
• Plan for provision of adequate staff initiated. This may require cancellation of elective cases and re-allocation of nursing staff.

• When these rooms are full, 3W will be closed to all other patient types.
• Non-ERI patients will be moved to other areas of the hospital.
• Plans initiated to open an alternate site for care of ERI patients outside of MHMH.
• ERI patients will continue to be admitted to 3West until alternate care site is opened. Other units of the hospital may need to accept patients (non ERI) from 3W. Other areas of the hospital may need to close some beds in order to pro vide extra staff to 3W.

• ERI patients who are known to have transmitted ERI to others.
• Patients who are being assessed for ERI (do not want to put someone who does not ultimately have ERI in with known ERI patients).

• Expedite transferring current patient to another room
• Notify engineering of the admission, engineering will ensure negative pressure is functioning in the room (This can be done by holding a small strip of tissue paper at the closed door and observing to be sure that it is pulled toward the room, not blown out away from the room. Engineering can assist with this if needed.)
• Ensure the room's pressure monitor alarm has been turned on and is working. Use the key to turn the room pressure monitor to "Infectious Isolation - Negative Pressure". This only turns the room alarm on, the room is always on negative pressure and does not need to be turned on. The alarm should go on when the door is left open for more than 1 minute or the seal is not adequate to maintain negative pressure in the room. Before the patient arrives to the room, check the room pressure monitor to be sure it is working by opening door, the alarm should go off after 1 minute. If there are questions about the monitor or room call Engineering. Monday through Friday 0800-1600 Ext. 57150. At other times use Engineering Pager #9234.
• Ensure unnecessary equipment (extra chairs, cot) is removed from the room
• Ensure that protective equipment is available in the anteroom (masks, gowns, goggles, gloves, PAPR units); Masks and goggles can be obtained from Stores, gowns from Linen Service ext. 57136, and PAPR units are in the Emergency Department. If rooms without an anteroom are used for a ERI patient the necessary equipment will need to be set up on a cart outside the room.

• The nurse caring for the patient will transport the patient with the assistance of transportation personnel as needed.
• If an elevator is needed, use a service elevator and be sure there are no other people in it.
• The patient must wear a surgical mask over their nose and mouth during transport through the institution.
• Security (ext. 5-7896) can help with providing an empty elevator available and other logistics if needed.
• Employees who are transporting the patient should wear gloves, N95 mask (or PAPR hood and motor unit), goggles, and gown.

• N95 mask (employee must have been fitted and trained by an administrator of the Respiratory Protection Program) and goggles (face shields are not felt to provide adequate protection).
• If the employee cannot be fitted for an N95 mask they must wear a PAPR unit when entering the room. (People wearing a PAPR hood do not need goggles; the hood provides protection for the eyes.)
• Everyone must wear gloves and a gown.

• Untie the gown's waist tie
• Remove gloves and dispose of them in trash
• Remove goggles handling them by the side pieces and place in sink
• Remove mask handling it by the head straps and dispose of in trash
• Untie neck ties of gown and carefully remove gown turning sleeves inside out as arms are pulled out, place gown in linen bag
• Put new gloves on and disinfect goggles with alcohol or Dimension III
• Remove gloves and dispose
• WASH HANDS before doing anything else.

• Remove hood and motor unit and place on chux pad
• Remove gloves, dispose of them in trash and put new gloves on, clean hood, hose and motor with Dimension III, place unit in clean area and dispose of chux pad
• Untie the gown's waist tie
• Remove gloves and dispose of them in trash
• Untie neck ties of gown and carefully remove gown turning sleeves inside out as arms are pulled out, place gown in linen bag
• WASH HANDS before doing anything else. pulled out, place gown in linen bag.

• No exposure
• Unprotected exposure but no symptoms
• Unprotected exposure with symptoms but do not meet the ERI case definition
• Symptoms meet the ERI case definition

• 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.
• Aching muscles
• Cough
• Headache
• Joint aches
• Eye pain
• Feeling very cold or having shaking chills
• Feeling very tired
• Sore throat, runny or stuffy nose

If you have some of these symptoms:


But IF you Or IF you

CALL your healthcare provider       GO RIGHT AWAY for healthcare

• Extreme fatigue
• Muscle and body aches
• Feeling very cold or having shaking chills
• Joint aches
• Headache (may be severe)
• Eye pain
• Sore throat
• Stuffed nose or runny nose
• Dry cough initially, may become a deep, hacking, and painful cough over the course of several days
• No appetite for food or desire to drink fluids

• Thermometer
• Acetaminophen
• Cough suppressants/cough syrup
• Drinks-fruit juices, sports drinks
• Light foods-clear soups, crackers, applesauce
• Blankets; warm covers

• Comfort measures
  • Have the patient rest in bed.
  • Allow the sick person to judge the amount of bed covers needed; when fever is high the person may feel very cold and want several blankets.
  • Give acetaminophen or ibuprofen according to the package label or a health care provider's direction to reduce fever, headache, and muscle, joint or eye pain.
  
  
• Fluids-give frequently, extremely important to replace body fluids that are lost as a result of fever.
• Feeding
  • Give light foods as the person wants: fluids are more important than food, especially in the first days when the fever may be highest.
  
  

• If the person is short of breath or breathing rapidly at rest
• If the person's skin is dusky or bluish in color
• If the person is disoriented ("out of it")
• If the person is so dizzy or weak that standing is difficult (in a person who was able to walk before the illness)
• If the person has not urinated in 12 or more hours

1. List may not include all test kits approved by the U.S. Food and Drug Administration.
2. NP = nasopharyngeal.
3. Shell vial culture, if available, may reduce time for results to 2 days.
4. Does not distinguish between influenza A and B virus infections.
5. RT-PCR = reverse transcriptase polymerase chain reaction.
6. A fourfold or greater rise in antibody titer from the acute- (collected within the 1st week of illness) to the convalescent-phase (collected 2-4 weeks after the acute sample) sample is indicative of recent infection.
7. Moderately complex test – requires specific laboratory certification.
8. CLIA-waived test. Can be used in any office setting. Requires a certificate of waiver or higher laboratory. certification.
9. Distinguishes between influenza A and B virus infections. Disclaimer: Use of trade names or commercial sources is for identification only and does not imply endorsement by the Centers for Disease Control and Prevention or the Department of Health and Human Services.

1. Hospital Preparedness Checklist
   (Department of Health and Human Services)
   http://www.hhs.gov/pandemicflu/plan/sup3.html#app2
2. Long-term Care and Other Residential Facilities Pandemic Influenza Planning Checklist
   (Department of Health and Human Services)
   http://www.pandemicflu.gov/plan/LongTermCareChecklist.html
3. Medical Offices and Clinics Pandemic Influenza Planning Checklist
   (Department of Health and Human Services)
   http://www.pandemicflu.gov/plan/medical.html
4. Emergency Medical Services and Non-emergent (Medical) Transportation Organizations
   Pandemic Influenza Planning Checklist
   (Department of Health and Human Services)
   http://www.pandemicflu.gov/plan/emgncymedical.html
5. Home Health Care Services Pandemic Influenza Planning Checklist
   (Department of Health and Human Services)
   http://www.pandemicflu.gov/plan/healthcare.html
6. Department of Veterans Affairs (VA)
   VA Pandemic Influenza Plan Appendix D-2: Sample Emergency Management Program
   Standard Operating Procedure (SOP)
   http://www.publichealth.va.gov/flu/pandemicflu_plan.htm#

1. Agent. A pandemic occurs when a new strain of influenza virus emerges that has the ability to infect and be passed between humans. Because humans would have little immunity to the new virus, a worldwide epidemic, or pandemic, can ensue. Influenza viruses have threatened the health of human populations for centuries. The diversity and propensity of influenza viruses for mutation have thwarted efforts to develop both a universal vaccine and highly effective antiviral drugs. As a result, and despite annual vaccination programs and modern medical technology, even seasonal influenza in the United States results in approximately 36,000 deaths and 226,000 hospitalizations each year. A pandemic strain of influenza could cause manyfold more. Transmission of influenza is aided by the fact that infected people may shed virus and spread the infection for one-half day to one day before symptoms begin.
2. Clinical Disease. Symptoms of influenza typically begin two days after exposure, often starting with a sudden onset of fever, severe fatigue or muscle pain, sore throat, and a dry cough. Uncomplicated seasonal influenza commonly leads to three to five days of acute illness, including fever and prostration, leaving the sufferer feeling weakened and with a residual cough for two or more weeks longer. A new strain may present a different clinical course and be much more serious, causing severe morbidity and mortality from influenza pneumonia or pneumonitis and secondary bacterial infections.
3. Public Health Response. Public health measures to slow or stop a pandemic influenza will likely include a number of actions that will have a range of success. A monovalent influenza vaccine made for the specific pandemic strain will be manufactured, but this will take several months. An antiviral medication, oseltamivir, that can be given to exposed persons to prevent illness and help limit transmission is available but supplies are limited and manufacturing is a complex process. Oseltamivir may be effective against the H5N1 avian influenza that has infected humans in Asia and Europe; VA holds a 500,000 treatment course stockpile of oseltamivir. Other public health measures include commonsense actions, like hand washing, respiratory hygiene, staying home when sick, and using telework or telecommuting options when able. Health care facility actions involve isolating the sick, having staff wear appropriate personal protective equipment (PPE), and screening for influenza illness or exposure before permitting entry to a facility. Community, regional, and nationally-mandated measures may include declaration of "snow days", postponing of large public gatherings, quarantine of the exposed, and restrictions on travel.

• An influenza pandemic can quickly overwhelm a VA medical center's or community-based outpatient clinic's normal capacity to provide timely and accessible medical care. Because of the ease with which influenza is transmitted, healthcare facilities can quickly become sites of intensive exposure for staff and non-infected patients. Breaks in procedure or unanticipated exposures may overwhelm a whole Medical Center, for example, by exposing personnel and requiring quarantine of the Medical Center. For this reason it is incumbent that VHA facilities prepare for the possibility of an influenza pandemic.
• An influenza pandemic can quickly overwhelm a hospital's or CBOC's mission critical systems, causing such problems as:
• Staffing shortages from community quarantine and competing family interests.
• Depleted supplies of vaccines and antivirals.
• Stretched bed capacity and operational space required for patient care or quarantine.
• A pandemic, by definition, will be a wide-spread-even national-event, so close coordination and cooperation with local, county, state public health agencies; and private sector healthcare facilities will be necessary and vital. It will also be necessary for VA medical centers to anticipate VA's mission to back up the Department of Defense (and provide care to designated members of the military) and VA's responsibilities to the National Response Plan (and provide care and resources for care to non-enrolled veterans and non-veterans).

• Facility Director – Responsible for assuring the organization implements the necessary preparatory measures for a potential influenza pandemic. The Director is also responsible for initiating the organization's disaster plan.
• Infection Control Team/Epidemiology– Key role in: tracking potential and confirmed cases; infection control management of patients using airborne precautions (private room, negative airflow, N95 respirator use by staff) or, when the Medical Center is overwhelmed, using droplet precautions and cohorting (isolation of infectious patients together, but away from non-exposed); working with and reporting to local and state public health agencies; serving as a VA medical center information resource on changing public health recommendations and on the community/outbreak; assisting with vaccination decisions affecting staff and patients; and advising on mass distribution systems for vaccine and antivirals.
• Engineering Service– Key role in: assessment of negative airflow rooms and negative airflow systems; identification of areas suitable for cohorting patients both in waiting areas and after hospitalization.
• Clinical Laboratory– Key role in: obtaining and performing diagnostic tests for the pandemic strain; knowing availability of reference laboratories for diagnosis (like the CDC's Laboratory Response Network [LRN] or state laboratories); advising on specimen collection; safe handling, storage, and shipping of specimens.
• Safety/Industrial Hygiene– Key role in: support of N95 respirator usage (fit testing) program.
• Police and Security– Key role in: crowd control, managing the flow of patients and visitors. If the situation warrants, police have key role in perimeter control, site access. Police may be called upon to protect the supply of influenza vaccines and supplies like oseltamivir, vaccine, N95 masks, and surgical or procedure-type masks. Perimeter access and site control may pertain to staff, staff relatives/family, and patients and require ingress and egress control. Site control may include assisting with drive-through triage stations or drive-through clinic sites, and mass distribution of vaccine and antivirals.
• Medical Service– Key role in: clinical diagnosis of cases; treatment of cases; providing healthcare advice via telephone; staffing innovative care delivery sites, advising/assisting with mass delivery of vaccine and antivirals.
• Nursing Service– Key roles in: staffing and bed support for inpatient, outpatient, and innovative care delivery sites; assisting with restriction of non-essential personnel from patient rooms (i.e., environmental management service, nutrition and food service personnel); providing healthcare advice via telephone; advising/assisting with mass delivery of vaccine and antivirals.
• Emergency Department– Key role in: monitoring incoming patients suspected of exposure or disease; making decisions on maintaining separate clinical activities.
• Pharmacy– Key role in managing the supply of vaccines and antivirals.
• Employee/Occupational Health– Key role in: employee vaccination/clinical care (identification of vaccine contraindications), information flow/risk communication to staff; advising/assisting with advice to staff about their ability to work, maintaining healthcare records for staff, including immune status.
• EMS/Safety– Key role in: advising on cleaning of rooms; equipment; communication of advice on cleaning measures.
• Volunteer Service– Key role in: coordinating volunteers (existing and community members) willing to assist. Volunteers also should assist in establishing an area for child care and respite for healthcare facility staff unable to leave the facility.
• Public Affairs– Key role in: keeping staff and patients informed, updating website, working with VSOs, media.

1. Hazard Reduction.
   • Notification/risk communications plan.
   • Activation of hospital emergency plan.
   • Perimeter control potential: need for increased security staffing, heightened security requirements for access control.
   • Building systems assessment for cohorting potential and confirmed patients.
   • Implementation of measures to provide added capacity for a potential surge of inpatient and ambulatory care.
   • Exposure control/Infection control: Airborne Infection Isolation and Contact Precautions are advised for a potentially lethal strain of pandemic influenza, in order to maximally protect staff. Patients should be placed in room with negative airflow and HEPA exhaust; and should wear surgical masks when transported through the Medical Center. If facilities are unable to exercise this degree of isolation, cohorting of patients in common, exposed areas with HVAC isolation and exhaust (if possible) and use of respiratory droplet precautions by staff are advised.
   • Separation of new, unexposed patients from potential pandemic influenza cases.
   • Use of Airborne Infection Isolation and Contact Precautions, if possible, or Droplet Precautions.
   • Visitor restriction policies.
   • If necessary, control of the perimeter: need for increased security staffing, heightened security requirements for access control.
2. Preparedness Strategies and Resources.
   • Establishment of Pandemic Response Team that will be prepared to work during a pandemic.
   • Vaccination (if available).
   • Antiviral medications prescribed to prevent illness in the exposed or unvaccinated (if available).
   • Public health measures of hand washing, respiratory hygiene, staying home when ill, respecting quarantine, isolation, "snow day" and travel, and public gathering limitations.
   • Education (on public health measures, infection control guidelines, home care, self-triage [to determine when medical care is necessary]).
   • Plan for Airborne Infection Isolation and Contact Precautions for all personnel with patient contact.
   • Anticipation of need to manage a large number of fatalities.

1. Hazard Control and Monitoring Strategies.
   • First case identified at a VAMC.
     1. Should be immediately reported: any suspected case(s) of pandemic influenza to Infection Control for confirmation. Infection Control would then brief the Chief of Medicine and the Chief of Staff. If case is confirmed, the Director, Safety Officer, Police and Occupational Health would be notified (this will most likely occur when a known pandemic virus is circulating elsewhere in the world and a VA medical center suspects it has the first U.S. or regional case).
     2. Activate Infection Control Team for initiation of patient/exposed staff tracking system, patient/staff educational information.
     3. Clear all patients and employees from the vicinity of the suspected case.
     4. Document details of incident and names of all persons within the immediate "at risk" area (i.e., who have become contacts and may require quarantine, antiviral medications).
     5. Contact local/state public health contacts for diagnostic sample collection and shipping instructions.
     6. Contact local/state public health agencies, Pharmacy Benefits Management, or VACO Office of Public Health and Environmental Hazards to obtain vaccine, depending on guidance provided at the time (if pandemic vaccine is available).
     7. Contact Pharmacy Benefits Management, or VACO Office of Public Health and Environmental Hazards for access to VA's oseltamivir (antiviral medication) stockpile.
     8. Activate Infection Control Team for initiation of patient/exposed employee tracking system, patient/employee educational information.
     9. Initiate antiviral medication for all potential exposed persons as appropriate after discussion with local/state public health agencies, if appropriate.
     10. Notify internal personnel, as appropriate, including Chief of Staff, Health Care Providers, Nursing Service, Pharmacy, Microbiology Laboratory, and Engineering for immediate inventory of critical resources.
     11. Immediately assess potential impact of actual event on mission-critical systems to include staffing, critical supplies, operational space, potential for patient and staff exposures and HVAC system.
   • Cases already identified among existing enrolled veterans.
     1. VA personnel must maintain communications and awareness with local and state public health agencies of progression of the pandemic in the community. Information must be shared with internal VA personnel, including VAMC Director, Chief of Staff, Police and Security, Chief Nurse Executive, Safety Officer/Industrial Hygienist, Employee/Occupational Health, Emergency Room Personnel, Health Care Providers, Pharmacy, and Microbiology Laboratory for immediate inventory of critical resources.
        1. Perform active surveillance for pandemic influenza appearing among hospitalized inpatients, or outpatients according to the prevailing case definition.
        2. Notify the Clinical Microbiology Laboratory of potential for use of rapid diagnostic tests or sending of specimens to reference laboratories.
        3. Immediately assess potential impact of reported community events on mission critical systems to include staffing, critical supplies and operational space.
        4. Await follow-up information from local authorities and prepare for potential presentation of patients.
2. Resource Issues.
   • Staffing needs will be monitored and addressed by Chief of Staff, Chief of Nursing, VAMC Director, and other involved Service Chiefs.
   • Critical Supplies – Vaccine (if available at the time) will likely be distributed through state health departments or through VA Central Office Pharmacy Benefits Management Strategic Healthcare Group. Additional timely information about vaccine may be expected from VACO. Other critical supplies to assess in the event of pandemic influenza include respiratory support equipment (oxygen, and oxygen-delivery equipment, ventilators), personal protective equipment, antimicrobial soap and alcohol-based hand cleaners, antibiotics to treat secondary bacterial pneumonias, morgue kits.
   • Resource Allocation – Develop criteria and transparent processes for allocation decisions regarding resources that may not be available in sufficient quantities during a pandemic: antivirals, respirators, vaccines, staff.
   • Space Management – Assess negative airflow room and cohorting bed and space availability; refrigerated space to store bodies.
   • Emergency Room capabilities, acute care clinic capabilities and current/projected bed availability should be immediately assessed.
   • Exposed patients and staff might expect short-term quarantine on site or relocation to alternate care sites or alternate healthcare facilities.
   • Consideration should be given to providing pandemic influenza countermeasures that are in short supply to staff members' families (vaccine, antivirals, personal protective equipment), depending on availability and on the facility's responsibilities and assignments under the National Response Plan. If staff members' families can be protected, staff will be more available to take care of patients.
3. Clinical Response.
   • Treatment protocols will be based upon prevailing knowledge of the pandemic influenza strain and will include supportive care (respiratory support, hemodynamic support) and use of antivirals.
   • Clinical admission/treatment decisions will be made by the health care providers.
   • All quarantine and visitor restriction decisions will be made by the VAMC Director based upon recommendations of the Infection Control Team or pandemic influenza response team following local/state public health guidance and decisions, and advice of regional VA counsel, if needed. Such decisions will be proportional to the disease impact, necessary, relevant, and applied equitably, and will employ the least restrictive means if options are available.
   • All patients treated and evaluated for potential pandemic influenza must be reported to the Infection Control Team or designated pandemic influenza response team for data collection.
   • Patient and staff recordkeeping must be maintained according to usual standards, if possible.
   • The Infection Control Team or designated pandemic influenza response team will monitor all potential cases and make appropriate reports to the VAMC Director and state and local public health agencies.
     
     Notes:
     1. Vaccination of Health Care Providers : Vaccine for a pandemic influenza strain will be developed once the strain is known. This vaccine will most likely be distributed to states and then to public and private medical centers. Changes and updates on vaccine availability will be communicated to VISNs and VAMCs from VACO.
        1. The Infection Control Team, or designated pandemic influenza response team, working with the Chief of Staff and VAMC Director will notify Health Care Providers when treatment/exposure guidelines are updated or as new resources are made available. The Infection Control Team can monitor the VA pandemic influenza websites for these updates. Note that VA guidance may differ from CDC guidance.
4. Recovery Strategies.
   • Periodic critical supply inventories with resupply or supplementation from outside facilities, as needed.
   • Periodic staffing census with workload redistribution, as needed.
   • Close monitoring of patient census and bed status.
   • Monitoring of staff and patient mental health.

1. Within VA. VISN, VACO.
2. Other State and Federal Agencies. Local and state public health departments who will notify CDC.
   • OSHA – follow prevailing rules for notification of employee fatalities and hospitalizations.
3. Community Entities. Neighboring hospitals, emergency response systems (police, firefighters, emergency medical services, 911 operators).

• Health Care Provider Training – Recognition of clinical syndromes associated with influenza, treatment protocols, guidelines for personal protective equipment.
• Infection Control Team Training – Passive and active surveillance systems for monitoring reportable infectious disease pathogens.
• Safety Specialist/Industrial Hygienist – N95 respirator usage.
• Clinical Laboratories – Diagnostic tests, specimen collection, handling, and shipping.
• Social Work Service – Introductory training on pandemic influenza, risks, treatments, family implications, and follow-up.
• Police and Security – Introductory training on pandemic influenza, PPE recommendations.
• Environmental Management Service Personnel – Introductory training on pandemic influenza risks, decontamination of environments, bed-clothing management, PPE recommendations.

• The VA Pandemic Influenza Plan.
• The VA Respiratory Infectious Diseases Emergency Plan (an amendment to the VHA Emergency Management Guidebook).
  Available at http://www.publichealth.va.gov/watch/respiratoryID.htm
• VHA Under Secretary for Health Influenza Advisories. Available at http://www.publichealth.va.gov/flu/advisory.htm
• Local, County, State Health Departments (24/7 contact information must be part of your emergency plans for pandemic influenza).
• VA guidance and websites on pandemic influenza www.publichealth.va.gov/infectiondontpassiton
  http://www.publichealth.va.gov/flu/pandemicflu.htm
• Federal websites on pandemic influenza
  www.pandemicflu.gov
• Phone Numbers.
  • VACO Office of Public Health and Environmental Hazards - 202-273-8575, 8567
  • VACO Pharmacy Benefits Management - 708786-7886

1. Department of Health and Human Services
   http://www.pandemicflu.gov/rcommunication/
   
   "Message maps" are risk communication tools used to convey complex information, and to make it easier to understand. Each primary message has three supporting messages that can be used to provide context for the subject of the primary message.
   
   http://www.pandemicflu.gov/rcommunication/pre_event_maps.pdf
2. Association of State and Territorial Health Officials
   http://www.astho.org/?template=risk_communication.html
3. Substance Abuse and Mental Health Services Administration
   http://www.riskcommunication.samhsa.gov/index.htm
4. World Health Organization
   http://www.who.int/csr/resources/publications/WHO_CDS_2005_31/en/
   http://www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdf
   http://www.who.int/csr/don/Handbook_influenza_pandemic_dec05.pdf

1. What is your name and title?
2. What are your job responsibilities?
3. What are your qualifications?
4. Can you tell us what happened?
5. When did it happen?
6. Where did it happen?
7. Who was harmed?
8. How many people were harmed?
9. Are those that were harmed getting help?
10. How certain are you about this information?
11. How are those who were harmed getting help?
12. Is the situation under control?
13. How certain are you that the situation is under control?
14. Is there any immediate danger?
15. What is being done in response to what happened?
16. Who is in charge?
17. What can we expect next?
18. What are you advising people to do?
19. How long will it be before the situation returns to normal?
20. What help has been requested or offered from others?
21. What responses have you received?
22. Can you be specific about the types of harm that occurred?
23. What are the names of those who were harmed?
24. Can we talk to them?
25. How much damage occurred?
26. What other damage may have occurred?
27. How certain are you about damages?
28. How much damage do you expect?
29. What are you doing now?
30. Who else is involved in the response?
31. Why did this happen?
32. What was the cause?
33. Did you have any forewarning that this might happen?
34. Why wasn't this prevented from happening?
35. What else could go wrong?
36. If you are not sure of the cause, what is your best guess?
37. Who caused this to happen?
38. Who is to blame?
39. Could this have been avoided?
40. Do you think those involved handled the situation well enough?
41. When did your response to this begin?
42. When were you notified that something had happened?
43. Who is conducting the investigation?
44. What are you going to do after the investigation?
45. What have you found out so far?
46. Why was more not done to prevent this from happening?
47. What is your personal opinion?
48. What are you telling your own family?
49. Are all those involved in agreement?
50. Are people overreacting?
51. Which laws are applicable?
52. Has anyone broken the law?
53. How certain are you that mistakes have not been made?
54. Have you told us everything you know?
55. What are you telling us?
56. What effects will this have on the people involved?
57. What precautionary measures were taken?
58. Do you accept responsibility for what happened?
59. Has this ever happened before?
60. Can this happen elsewhere?
61. What is the worst case scenario?
62. What lessons were learned?
63. Were those lessons implemented? Are they being implemented now?
64. What can be done to prevent this from happening again?
65. What would you like to say to those who have been harmed and to their families?
66. Is there any continuing danger?
67. Are people out of danger? Are people safe?
68. Will there be inconvenience to employees or to the public?
69. How much will all this cost?
70. Are you able and willing to pay the costs?
71. Who else will pay the costs?
72. When will we find out more?
73. What steps need to be taken to avoid a similar event?
74. Have these steps already been taken?
75. If not, why not?
76. Why should we trust you?
77. What does this all mean?

• Consumable resources
  • Hand hygiene supplies (antimicrobial soap and alcohol-based, waterless hand hygiene products)
  • Disposable N95 respirators, surgical and procedure masks
  • Face shields (disposable or reusable)
  • Gowns
  • Gloves
  • Facial tissues
  • Central line kits
  • Morgue packs
• Durable resources
  • Ventilators
  • Respiratory care equipment
  • Beds
  • IV pumps

• Mechanical ventilators
• Manual resuscitators (bag-valve mask)
• Beds
• Stretchers/gurneys
• IV pumps
• Positive air purifying respirators (PAPRs) or other equivalent respirators

• Hand hygiene supplies (antimicrobial soap and alcohol-based [>60%], waterless hand hygiene gels or foams)
• Disposable fit-testable N95 respirators
• Elastomeric respirators with P100 filters
• Surgical and procedure-type masks
• Goggles
• Gowns
• Gloves
• Facial tissues
• Central line kit
• Morgue packs
• IV equipment
• Syringes and needles for vaccine administration
• Respiratory care equipment
  • Portable oxygen
  • Regulators and flow meters
  • Oxygen and ventilator tubing, cannulae, masks
  • Endotracheal tubes, various sizes
  • Suction kits
  • Tracheotomy
  • Vacuum gauges for suction and portable suction machines
• Intensive care unit (ICU) monitoring equipment

• Nonsteroidal anti-inflammatory drugs (NSAIDs), pill and liquid forms
• Acetaminophen (pill, suppository, liquid)
• Antibiotics (consider ciprofloxacin, levofloxacin po and iv, vancomycin, piperacillin/tazobactam, ceftriaxone)
• Antivirals (oseltamivir)
• Vaccines (pandemic and seasonal influenza, pneumococcal)
• Vasopressors
• Benzodiazepines, propofal
• Proton pump inhibitors
• Bronchodilators

• Thermometers
• NSAIDs or acetaminophen
• Cough suppressants
• Oral rehydration mix packs
• Surgical or procedure-type masks for the patient to wear around others and for care providers to wear around the patient
• Printed home care instructions, including VA facility contact information and information about symptoms that should prompt the patient to see a healthcare provider

• Management leadership and employee involvement,
• Worksite analysis,
• Hazard prevention and control, and
• Safety and health training.

• file a complaint online,
• submit general inquiries about workplace safety and health electronically, and
• find more information about OSHA and occupational safety and health.