2009-2010 Influenza Season Update #5
New CDC Interim Infection Control Guidance

October 30, 2009

To:   Healthcare Providers, Hospital Emergency Departments, Clinical Laboratories, Infection Control Practitioners, Pharmacists, Dental Health Professionals, Emergency Medical Service Personnel, School Nurses

From: Wendy Davis, MD, Commissioner of Health

– Please Distribute Widely –

On October 14, 2009, the Centers for Disease Control & Prevention (CDC) issued updated Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, including Protection of Healthcare Personnel. See the complete document at: www.cdc.gov/h1n1flu/guidelines_infection_control.htm

Links to two CDC Question and Answer documents related to the updated guidance and respiratory protection are also available: www.cdc.gov/h1n1flu/guidance/control_measures_qa.htm and www.cdc.gov/h1n1flu/guidelines_infection_control_qa.htm 

Italicized sections that follow are taken directly from the guidance.

CDC guidance is updated periodically as new information becomes available. The updated guidance applies uniquely to the special circumstances of the current 2009 H1N1 pandemic and will be updated as necessary as new information becomes available throughout the course of this influenza season. Check the CDC website for the latest information at www.cdc.gov/h1n1flu

The Vermont Department of Health is working with hospitals and other health care partners statewide to assure implementation of respiratory protection control plans that utilize the most current guidance, including the monitoring of infection control supply inventories and use patterns. Facilities should monitor Personal Protective Equipment (PPE) inventory and use patterns frequently in order to recognize and minimize gaps between supply and demand. Anticipated shortages should be addressed as early as possible.

NOTE: Occupational Safety and Health Administration (OSHA) inspections to assure compliance are a possibility in response to complaints. For questions regarding OSHA’s reliance on CDC guidelines when establishing worker protection standards, contact the OSHA regional office directly. See www.osha.gov for more information.

A wide variety of applicable personnel and locations are described. The guidance applies to healthcare personnel working in the following settings: acute care hospitals, nursing homes, skilled nursing facilities, physician’s offices, urgent care centers, outpatient clinics, and home healthcare agencies.  It also includes those working in clinical settings within non-healthcare institutions, such as school nurses or personnel staffing clinics in correctional facilities. The term “healthcare personnel” includes not only employees of the organization or agency, but also contractors, clinicians, volunteers, students, trainees, clergy, and others who may come in contact with patients.

The guidance recommends that facilities use a “Hierarchy of Controls” to prevent 2009 H1N1 exposure and transmission. The hierarchy of controls to protect workers from occupational injury or illness places preventive interventions in groups that are ranked according to their likely effectiveness in reducing or removing the source of exposure. To apply the hierarchy of controls to prevention of influenza transmission, facilities should take the following steps, in order of preference:

Airborne Transmission Precautions

CDC continues to recommend the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza. This recommendation applies uniquely to the special circumstances of the current 2009 H1N1 pandemic during the fall and winter of 2009-2010 and CDC will continue to revisit its guidance as new information becomes available, within this season if necessary.

Prioritization where Shortages of Airborne Transmission-related PPE Exist

The guidance acknowledges that shortages of supplies of respirators and other PPE recommended to prevent airborne transmission of 2009 H1N1 flu may occur. It also offers strategies to prioritize use where shortages exist.

Although the exact total supply in the public and private sectors is not known, a large gap between supply and demand is predicted.

Special care should be taken to ensure that respirators are available for situations where respiratory protection is most important, such as performance of aerosol-generating procedures on patients with suspected or confirmed 2009 H1N1 influenza or provision of care to patients with other infections for which respiratory protection is strongly indicated (e.g., tuberculosis).

Monitoring Supplies and Usage

The Vermont Department of Health recommends facilities and other healthcare employers monitor PPE inventory and use patterns more frequently as flu activity and PPE use increase in order to recognize and minimize gaps between supply and demand. Address shortages in PPE as early as possible. Maintain a reserve of PPE for procedures likely to generate pathogen-containing aerosols.

Prioritization of PPE

Where a shortage of respirators exists despite reasonable efforts to obtain and maintain a sufficient supply for anticipated needs, in particular for very high exposure risk situations such as some aerosol-generating procedures (listed below), a facility should consider shifting to a prioritized respirator use mode. In this mode, respirator use is prioritized to ensure availability for healthcare personnel at most risk from 2009 H1N1 influenza exposure. Even under conditions of prioritized use, personnel attending aerosol-generating procedures on patients with suspected or confirmed 2009 H1N1 influenza should always use respiratory protection at least as protective as fitted N95 respirators.

Although some have suggested that administration of nebulized medications (due to risk of inducing cough), acquisition of nasopharyngeal swabs/samples, and use of high-flow oxygen might create infectious aerosols of concern, less is known about the magnitude or potential for exposure. (Note: for additional detail regarding measures to reduce exposures from high-risk aerosol-generating procedures, refer to complete document.)

Prioritization should be adapted to local conditions and should consider intensity and duration of exposure, personal health risk factors for complications of infection, and vaccination status. When in prioritized respirator use mode, respirator use may be temporarily discontinued for employees at lower risk of exposure to 2009 H1N1 influenza or lower risk of complicated infection.

Table 2 below appears in the CDC guidance and offers additional prioritization strategies for PPE use in situations not likely to generate virus-containing aerosols.

Table 2. Prioritization of Respiratory Protection During Respirator Shortages for Healthcare Personnel Not Participating in Aerosol-Generating Procedures (a).

Numbers 1 through 4 indicate relative priorities for respiratory protection.
1 reflects highest priority; 4 lowest priority.

Exposure Scenario

Not Vaccinated (b)

Vaccinated(c)

Personnel Without Risk Factors for Influenza-Related Complications (d)

Routine care – frequent close exposure (e)

2

4

Routine care – infrequent close exposure (f)

3

4

Personnel With Risk Factors for Influenza-Related Complications (g)

Routine care – frequent close exposure

1

3

Routine care – infrequent close exposure

2

4

a  This table provides an example of prioritization that considers intensity and duration of exposure, personal health risk factors for complications of infection, and vaccination status. Advance planning is critical to efficient implementation of prioritized use during supply shortages.

b  Not vaccinated: not vaccinated or less than 14 days after vaccination. Consider including those with immunosuppressive conditions or treatment with immunosuppressive therapies anticipated to impair vaccine response in this group.

c  Vaccinated: 14 or more days after vaccination.

d  See section on “Healthcare Personnel at Higher Risk for Complications of Influenza” for list of personal risk factors for influenza-related complications; also see: http://www.cdc.gov/h1n1flu/recommendations.htm.

 e  Personnel frequently in close contact with patients with suspected or confirmed 2009 H1N1 influenza. For the purposes of this document, close contact is defined as working within 6 feet of the patient or entering into a small enclosed airspace shared with the patient (e.g., average patient room). This generally includes personnel working in settings where cases of suspected or confirmed 2009 H1N1 influenza are routinely seen (e.g. emergency departments and primary care in environments such as clinics in outpatient settings, employee healthcare facilities, and correctional facilities).

f  Personnel infrequently in close contact with patients with suspected or confirmed 2009 H1N1 influenza. This generally includes personnel working in settings where cases of suspected or confirmed 2009 H1N1 influenza are not routinely seen and/or having job duties not involving close contact.

g  Gathering of personal information for the purposes of pandemic planning and response must be done in a fashion that is compliant with all applicable rules and regulations, including the Americans with Disabilities Act (ADA). A short technical assistance document is available at the following web address: www.eeoc.gov/facts/pandemic_flu.html

Consider offering alternative work environments as an accommodation for employees at highest risk for complications of influenza during periods of increased influenza activity or if influenza severity increases.

To assure that respirators are likely to be available for the most important uses, facilities should maintain a reserve sufficient to meet the estimated needs for performing aerosol-generating procedures and for managing patients with diseases other than influenza that require respiratory protection until supplies are expected to be replenished.

Facemasks for healthcare personnel who are not provided a respirator due to the implementation of prioritized respirator use: If a facility is in prioritized respirator use mode and unable to provide respirators to healthcare personnel who provide care to suspected and confirmed 2009 H1N1 influenza cases, the facility should provide those personnel with facemasks. Facemasks that have been cleared for marketing by the U.S. Food and Drug Administration have been tested for their ability to resist blood and body fluids, and generally provide a physical barrier to droplets that are expelled directly at the user. Although they do not filter small particles from the air and they allow leakage around the mask, they are a barrier to splashes, droplet sprays, and autoinoculation of influenza virus from the hands to the nose and mouth. Thus, they should be chosen over no protection. Routine chemoprophylaxis is not recommended for personnel wearing facemasks during the care of patients with suspected or confirmed 2009 H1N1 influenza.

Resource: the Vermont Department of Health’s website provides Respiratory Protection Program information and templates in the EMS section. See: healthvermont.gov/hc/ems/ems_index.aspx

 

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