|
U.S. Department of Labor | |
||||
| Occupational Safety & Health Administration | ||||||
 |
|
Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers
Occupational Safety and Health Administration U.S. Department of Labor OSHA 3328-05 2007 Employers are responsible for providing a safe and healthful workplace for their employees. OSHA's role is to assure the safety and health of America's working men and women by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual process improvement in workplace safety and health. This publication is in the public domain and may be reproduced, fully or partially, without permission. Source credit is requested, but not required. This information is available to sensory impaired individuals upon request. Voice phone: (202) 693-1999; teletypewriter (TTY) number: (877) 889-5627. Edwin G. Foulke, Jr.
Contents [Introduction] [References] [Influenza: Clinical Background Information] [Clinical Presentation of Influenza] [Clinical Presentation of Seasonal Influenza] [Clinical Presentations of Prior Influenza Pandemics] [Clinical Presentation of Highly Pathogenic Avian Influenza in Humans] [Diagnosis] [Clinical Diagnosis of Seasonal Influenza] [Laboratory Diagnosis of Seasonal Influenza] [Clinical Diagnosis of Pandemic Influenza] [Laboratory Diagnosis of Avian and Pandemic Influenza] [Modes of Transmission] [Seasonal Influenza Transmission] [Pandemic Influenza Transmission] [Treatment and Prevention] [Seasonal Influenza Treatment and Prevention] [Pandemic Influenza Treatment and Prevention] [References] [Infection Control] [Standard Precautions and Transmission-Based Precautions] [Standard Precautions] [Contact Precautions] [Droplet Precautions] [Airborne Precautions] [Compliance with Infection Control] [Hand Hygiene Compliance] [Respiratory Protection Compliance] [Organizational Factors that Affect Adherence to Infection Control] [Facility Design, Engineering, and Environmental Controls] [Facility Capacity] [Engineering Controls in Improvised Settings] [Airborne Infection Isolation Rooms] [Engineering Controls for Aerosol-Generating Procedures for Patients with Pandemic Influenza] [Cohorting] [Engineering Controls in Diagnostic and Research Laboratories] [Autopsy Rooms for Cases of Pandemic Influenza] [Administrative Controls] [Respiratory Hygiene/Cough Etiquette] [Pandemic Influenza Specimen Collection and Transport] [Patient Transport within Healthcare Facilities] [Pre-Hospital Care and Patient Transport Outside Healthcare Facilities] [Staff Education and Training] [Care of the Deceased] [Patient Discharge] [Visitor Policies] [Healthcare Worker Vaccination] [Antiviral Medication for Prophylaxis and Treatment in Healthcare Workers] [Occupational Medicine Services] [Worker Protection] [Recommendations for Occupational Health Administrators] [Occupational Medical Surveillance and Staffing Decisions] [Personal Protective Equipment] [Gloves] [Gowns] [Goggles/Face Shields] [Respiratory Protection for Pandemic Influenza] [PPE for Aerosol-Generating Procedures] [Order for Putting on and Removing PPE] [Work Practices] [Hand Hygiene] [Other Hygienic Measures] [Facility Hygiene-Practices and Polices] [Laboratory Practices] [References] [Pandemic Influenza Preparedness] [Healthcare Facility Responsibilities During Pandemic Alert Periods] [Healthcare Facility Responsibilities During Pandemic Alert Periods (HSC Stages 0, 1)] [Healthcare Facility Responsibilities During the Pandemic (HSC Stages 2-5)] [Healthcare Facility Recovery and Preparation for Subsequent Pandemic Waves (HSC Stage 6)] [Incorporating Pandemic Plans into Disaster Plans] [Pandemic Planning for Support of Healthcare Worker Staff] [Define Essential Staff and Hospital Services] [Human Resources] [Information Technology] [Public Health Communications] [Surveillance and Protocols] [Psychological Support] [Occupational Health Services] [Developing and Providing Employee Screening for Influenza-Like Illness] [Developing and Providing Immunization and Treatment Strategies] [Continuing Baseline Occupational Health Services] [Training] [Security] [Stockpiles of Essential Resources] [Pandemic Influenza Vaccine] [Antiviral Medication] [Personal Protective Equipment] [Outpatient Services and Clinics] [Alternate Care Sites] [References] [OSHA Standards of Special Importance] [Respiratory Protection Standard 29 CFR 1910.134] [Personal Protective Equipment Standard - 29 CFR 1910.132] [Bloodborne Pathogens Standard - 29 CFR 1910.1030] [General Duty Clause] [References] [Appendix A Pandemic Influenza Internet Resources] [Appendix B Infection Control Communication Tools for Healthcare Workers] [Appendix B-1 Factors Influencing Adherence to Hand Hygiene Practices] [Appendix B-2 Elements of Healthcare Worker Educational and Motivational Programs] [Appendix B-3 Strategies for Successful Promotion of Hand Hygiene in Hospitals] [Appendix B-4 Pandemic Influenza Precautions for Veterans Administration Healthcare Facility Staff] [Appendix B-5 Public Health Measures Against Pandemic Influenza for Individuals, Healthcare Providers, and Organizations] [Appendix C Implementation and Planning for Respiratory Protection Programs in Healthcare Settings] [Appendix C-1 Respiratory Protection Programs] [Appendix C-2 Readiness Plan for Epidemic Respiratory Infection: A Guideline for Operations for Use by the Dartmouth-Hitchcock Medical Center – Lebanon Campus and the Dartmouth College Health Service] [Appendix D Self-Triage and Home Care Resources for Healthcare Workers and Patients] [Appendix D-1 Sample Self-Triage Algorithm for Persons with Influenza Symptoms] [Appendix D-2 Home Care Guide for Influenza] [Appendix E References for Diagnosis and Treatment of Staff During an Influenza Pandemic] [Appendix E-1 Influenza Diagnostic Table] [Appendix F Pandemic Planning Checklists and Example Plans] [Appendix F-1 Sample Emergency Management Program Standard Operating Procedure (SOP)] [Appendix G Risk Communication Resources] [Appendix G-1 Risk and Crisis Communication: 77 Questions Commonly Asked by Journalists During a Crisis] [Appendix H Sample Supply Checklists for Pandemic Planning] [Appendix H-1 Examples of Consumable and Durable Supply Needs] [Appendix H-2 Suggested Inventory of Durable and Consumable Supplies for Veterans Administration Healthcare Facilities During a Pandemic Influenza] [OSHA Assistance] [OSHA Regional Offices] Introduction A pandemic is a global disease outbreak. A flu pandemic occurs when a new influenza virus emerges for which people have little or no immunity, and for which there is no vaccine. The disease spreads easily person-to-person, causes serious illness, and can sweep across the country and around the world in a very short time. It is difficult to predict when the next influenza pandemic will occur or how severe it will be. Wherever and whenever a pandemic starts, everyone around the world is at risk. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but they cannot stop it. An especially severe influenza pandemic could lead to high levels of illness, death, social disruption, and economic loss. Everyday life would be disrupted because so many people in so many places become seriously ill at the same time. Impacts can range from school and business closings to the interruption of basic services such as public transportation and food delivery. An influenza pandemic is projected to have a global impact on morbidity and mortality, thus requiring a sustained, large-scale response from the healthcare community. The 1918 influenza pandemic was responsible for over 500,000 deaths in the United States, while the 1957 and 1968 pandemic influenza viruses were responsible for 70,000 and 34,000 deaths, respectively. 1 More recently, one modeling study estimated that an influenza pandemic affecting 15 to 35 percent of the United States population could cause 89,000 to 207,000 deaths, 314,000 to 734,000 hospitalizations, 18 to 42 million outpatient visits, and 20 to 47 million additional illnesses. 2 In contrast, from 1990 to 1999, seasonal influenza caused approximately 36,000 deaths per year in the United States. 3 A substantial percentage of the world's population will require some form of medical care. Healthcare facilities can be overwhelmed, creating a shortage of hospital staff, beds, ventilators and other supplies. Surge capacity at non-traditional sites such as schools may need to be created to cope with the demand. It is expected that such an event will quickly overwhelm the healthcare system locally, regionally, and nationally. 4 An increased number of sick individuals will seek healthcare services. In addition, the number of healthcare workers available to respond to these increased demands will be reduced by illness rates similar to pandemic influenza attack rates affecting the rest of the population. Finally, healthcare workers and healthcare resources will also be expected to continue to meet non-pandemic associated healthcare needs. In order to mitigate the effects of an influenza pandemic on the healthcare community, it is important to identify healthcare providers and recognize the diversity of practice settings.
The guidance document is organized into four major sections:
The document also contains appendices which provide pandemic planners with samples of infection control plans, examples of practical pandemic planning tools and additional technical information. Topic areas include Internet resources, communication tools, sample infection control programs, self-triage and home care resources, diagnosis and treatment of staff during a pandemic, planning and supply checklists and risk communication. This educational material has been provided for informational purposes only and should be used in conjunction with the entire document in order to ensure that healthcare workers are adequately protected during a pandemic. OSHA does not recommend one option over the many effective alternatives that exist. OSHA has prepared additional, general information to assist workplaces in their preparation for an influenza pandemic entitled, Guidance on Preparing Workplaces for an Influenza Pandemic which is available at www.osha.gov. [Table of Contents] References
Influenza: Clinical Background Information Historically, influenza has caused outbreaks of respiratory illness for centuries, including three pandemics (worldwide outbreaks of disease) in the 20th century. 1 There are three types of influenza viruses: types A, B, and C. Only type A influenza viruses cause pandemics. Seasonal influenza outbreaks can be caused by either type A or type B influenza viruses. Influenza type C viruses cause mild illness in humans but do not cause epidemics or pandemics. This guidance is aimed at protecting healthcare workers in the event of an influenza pandemic; therefore, the focus will be on the characteristics of type A influenza viruses. Of the three types of influenza viruses, only type A is divided into subtypes. Subtype designations are based on the presence of two viral surface proteins (antigens): hemagglutinin (H) and neuraminidase (N). To date, 16 different hemagglutinin and 9 different neuraminidase surface proteins have been identified in influenza A viruses. 2 Subtypes are designated as the H protein type (1–16) solely or followed by the N protein type (1–9) (e.g., H5N1). Three different subtypes (i.e., H1N1, H2N2, and H3N2) have caused pandemics in the 20th century. Influenza A viruses vary in virulence, infectivity to specific hosts, modes of transmission, and the clinical presentation of infection. Seasonal, avian, and pandemic influenza can occur in humans. It is important to have a basic understanding of the terms seasonal, avian and pandemic influenza in order to appreciate the guidance in this document.
As of November 2006, the spread of highly pathogenic H5N1 avian influenza virus from person to person has been limited to rare, sporadic cases. Nonetheless, because all influenza viruses have the ability to change, scientists are concerned that highly pathogenic H5N1 avian influenza virus one day could be able to sustain human-to-human transmission. Because these viruses do not commonly infect humans, there is little or no immune protection against them in the human population. If the highly pathogenic H5N1 avian influenza virus were to gain the capacity to sustain transmission from person to person, a pandemic could begin.
The first two phases of the WHO Pandemic Alert System comprise the "Inter-pandemic Period" in which there is a novel influenza A virus in animals, but no human cases have been observed. Phase 2 indicates that an animal influenza subtype that poses a risk to humans has been detected. The next three phases (Phases 3–5) compose the "Pandemic Alert Period" in which a novel influenza virus causes human infection with a new subtype, but does not exhibit efficient and sustained human-to-human transmission. Once a new influenza A virus develops the capacity for efficient and sustained human-to-human transmission in the general population (Phase 6), the WHO declares that an influenza pandemic is in progress (this is known as the "Pandemic Period"). For additional information visit WHO's Epidemic and Pandemic Alert and Response website at http://www.who.int/csr/disease/avian_influenza/phase/en/index.html. Federal government response stages to these WHO phases are described in the National Strategy for Pandemic Influenza: Implementation Plan which can be found at http://www.whitehouse.gov/homeland/pandemicinfluenza-implementation.html. [Table of Contents] Clinical Presentation of Influenza It may be useful for healthcare providers to be aware of the clinical presentation of seasonal influenza, prior influenza pandemics, and highly pathogenic avian influenza in humans to assist them when evaluating patients who present with influenza-like illness. The clinical picture of influenza infections can vary from no symptoms at all in seasonal influenza to fulminant (fully symptomatic) disease in pandemic strains that result in severe illness and death, even among previously healthy adults and children. 4 Fever and respiratory symptoms are characteristic of all forms of influenza. The Centers for Disease Control and Prevention's (CDC's) Sentinel Provider Network (SPN) monitors influenza timing and severity. The SPN 5 is comprised of approximately 2,300 primary care providers that provide weekly reports on outpatient "influenza-like illnesses" to state health departments and to the CDC. The SPN uses "fever >100° F or 37.8° C and sore throat and/or cough in the absence of a known cause other than influenza" as its definition of influenza-like illness. [Table of Contents] Clinical Presentation of Seasonal Influenza Seasonal influenza typically has an abrupt onset, with symptoms of fever, chills, fatigue, muscle aches, headache, dry cough, upper respiratory congestion, and sore throat. 6 The time from exposure to disease onset is usually 1 to 4 days, with an average of 2 days. Most patients recover within 3 to 7 days. 7 In adults, fevers usually last for 2 to 3 days, but may last longer in children. Cough and weakness can persist for up to 2 weeks. Except for fever, the physical examination has few specific findings. Typically there is weakness and mild inflammation of the upper respiratory tract. Routine outpatient laboratory findings are also non-specific. Available laboratory tests that are specific for influenza are described in the Diagnosis section on page 9 of this document. Adults are possibly infectious from about 1 day before until about 5 days after the onset of clinical illness. Children and the immunocompromised (e.g., people with HIV infection, organ transplantation or receiving chronic steroids) have a much longer period of infectivity. Children can be infectious for 10 or more days, and young children can shed the virus for several days before the onset of illness. Severely immunocompromised persons can shed the virus for weeks or months. 7 Seasonal influenza is responsible for approximately 36,000 deaths and 226,000 hospitalizations annually in the United States. 8 The risk of death is highest among the elderly, the very young, and patients with cardiopulmonary and other chronic conditions. 7 [Table of Contents] Clinical Presentations of Prior Influenza Pandemics The 1918 influenza pandemic, caused by subtype H1N1 viruses, had signs and symptoms of far greater severity than seasonal influenza. It resulted in death for an estimated 500,000 U.S. citizens and as many as 40 million people worldwide. The 1918 pandemic disproportionately affected young, healthy adults, between the ages of 15 and 35. A significant proportion of patients developed fulminant disease, accompanied by a striking perioral cyanosis, leading to death within a few days. Postmortem examinations in these patients frequently revealed denuding tracheobronchitis, pulmonary hemorrhage, or pulmonary edema. Others survived the initial illness, only to die of a secondary bacterial pneumonia. 6 The 1957 (caused by subtype H2N2 viruses) and 1968 (caused by subtype H3N2 viruses) influenza pandemics killed an estimated 70,000 and 34,000 U.S. citizens, respectively. 8 The clinical features of the pandemics of 1957 and 1968 were also typical of influenza-like illness, including fever, chills, headache, sore throat, malaise, cough, and coryza, but were milder compared to the 1918–19 pandemic. 6 The 1957 influenza pandemic was notable for severe complications, such as primary viral pneumonia, particularly in pregnant women. As in the pandemic of 1918, some people survived the initial viral infection, only to later die of a secondary bacterial pneumonia. [Table of Contents] Clinical Presentation of Highly Pathogenic Avian Influenza in Humans The highly pathogenic H5N1 avian influenza virus that caused outbreaks in Hong Kong, Thailand, Vietnam, and Cambodia, like the 1918 pandemic virus, primarily resulted in disease in children and young adults. 9 Hospitalized patients initially developed typical seasonal influenza symptoms such as high fever and cough, but unlike seasonal influenza, there were lower respiratory tract rather than upper respiratory tract symptoms. Because of the involvement of the lower respiratory tract, patients typically had shortness of breath and almost all patients had developed viral pneumonia at the time of hospitalization. Also unlike typical seasonal influenza, diarrhea, abdominal pain, and vomiting were frequently reported. Common laboratory findings were lymphopenia, thrombocytopenia and elevated aminotransferase levels. As of November 13, 2006, highly pathogenic H5N1 viruses had not been detected in animals or humans in the United States. For up-to-date information regarding the number of human cases of avian influenza and deaths worldwide, visit the WHO Confirmed Cases of Human Influenza A (H5N1) website at http://www.who.int/csr/disease/avian_influenza/country/en/. An outbreak of another avian influenza virus, H7N7, occurred among poultry farm employees and those helping to contain the outbreak in the Netherlands in 2003. 10 The clinical course of this influenza virus was unusual in that conjunctivitis was a common finding and fewer affected persons had respiratory symptoms, although the one fatality among the 89 human cases was associated with respiratory disease. No further outbreaks were reported through April 24, 2006 (http://www.cdc.gov/flu/avian/gen-info/avian-flu-humans.htm). [Table of Contents] Diagnosis Accurate and timely influenza diagnosis requires knowledge of the likely clinical presentations of seasonal influenza and of any circulating strains of novel viral subtypes, an awareness of the risks for exposure, and knowledge of the capabilities and limitations of laboratory diagnostic tests. The more quickly a new pandemic virus can be identified, the sooner actions can be taken to isolate the initial cases and initiate other public health measures to prevent spread through the community andthe sooner infection control measures can be implemented to protect the community's health-care workers. [Table of Contents] Clinical Diagnosis of Seasonal Influenza Uncomplicated seasonal influenza presents as a sudden onset of fever and respiratory illness with muscle aches, headaches, nonproductive cough, sore throat, and runny nose. Children can also have ear infections and/or gastrointestinal symptoms. 7 The diagnosis of the influenzas will be primarily through recognizing symptom complexes such as those used in surveillance. The SPN definition for influenza-like illness is used for seasonal influenza surveillance. 5 However, this definition is not specific and may share features with other respiratory illnesses present in the community. The likelihood of a clinical sign or symptom to accurately detect influenza infection in a group of patients is called sensitivity. Conversely, the likelihood of a clinical sign or symptom to exclude influenza infection in a group of patients who do not have influenza is called specificity. Both the sensitivity and specificity of clinical signs and symptoms of influenza infection vary with multiple factors, including patient age, vaccination status, hospitalization status, degree of co-circulation of other infectious agents that cause respiratory symptoms in the community, and the percentage of the population infected with influenza (prevalence). The clinical signs and symptoms of influenza have been studied using viral cultures as the criteria for definitive influenza diagnosis in groups of mostly young adults when influenza was circulating in their community. It has been reported that the use of the influenza-like case definition is 63 to 78% accurate in identifying culture-confirmed cases of influenza (a sensitivity of 63 to 78%) and 55 to 71% accurate in excluding influenza (specificity of 55 to 71%). 7 The sensitivity and specificity will vary based on the percentage of all respiratory illnesses that are due to influenza. Other studies have addressed influenza signs and symptoms in different groups. 11, 12 There is considerable overlap in the clinical presentation of seasonal influenza and other viral and bacterial respiratory infections. Influenza surveillance case definitions and laboratory testing can assist in differentiating among these infections. However, clinicians must always maintain a level of awareness that co-infections with bacterial respiratory infections or non-influenza viruses can occur with seasonal influenza. Clinical judgment regarding diagnosis and treatment is needed in conjunction with laboratory testing in order to differentiate between potential infectious organisms. [Table of Contents] Laboratory Diagnosis of Seasonal Influenza During Inter-pandemic and Pandemic Alert Periods, use of laboratory diagnostic tests for influenza supports seasonal influenza surveillance and provides laboratory detection of novel influenza subtypes. There are multiple laboratory techniques for identifying influenza viruses, including the rapid antigen test, the reverse transcriptase polymerase chain reaction (RT-PCR) assays, virus isolation, and immunofluorescence antibody assays. 13 When respiratory secretions are used for seasonal influenza diagnosis, nasopharyngeal samples are more likely to yield a positive result than are pharyngeal swab samples. 14 Commercial rapid testing can detect influenza virus in less than 30 minutes. However, some of these tests are not very sensitive 9 (false negative results are common) and not all of these tests are able to distinguish between influenza A and B viruses (see Safety Tips for Laboratorians: Cautions in Using Rapid Tests for Influenza A Viruses at http://www.fda.gov/cdrh/oivd/tips/rapidflu.html). When influenza is suspected during an outbreak of respiratory illness, both rapid testing and viral cultures should be done. Although viral cultures require five days or more to perform, they can provide specific information on the strain and subtype of the influenza virus tested, and provide information on the sensitivity to antiviral medication as well. 14 The HHS/CDC Influenza (Flu) Laboratory Diagnostic Procedures for Influenza website (http://www.cdc.gov/flu/professionals/labdiagnosis.htm) maintains a table of the available diagnostic tests for the influenza virus. 14 [Table of Contents] Clinical Diagnosis of Pandemic Influenza Patients with pandemic influenza will likely have clinical signs and symptoms similar to seasonal influenza, although the clinical presentation and course of illness may be severe in a higher percentage of the cases of pandemic influenza. In general, if the next pandemic is comparable to the 1918 Type A H1N1 virus, the pandemic influenza is likely to be far more severe than seasonal influenza, and might disproportionately affect a younger population. An important factor to look for when evaluating patients for the presence of pandemic influenza during all phases of a WHO Pandemic Alert Period, when human infection with a new subtype is detected, is a possible source of exposure. For instance, the current sources of exposure to highly pathogenic H5N1, the avian influenza virus of most concern, would likely involve international travel or occupational exposure to infected poultry or wild birds. Emergency room physicians and other healthcare personnel interviewing patients with influenza-like illness should ask about recent travel history. A patient who has a history of travel to a country affected by a novel influenza virus and who has the onset of influenza-like illness within the known incubation period for that virus should be suspected to be infected with the novel influenza virus. Seasonal influenza incubation is usually 1 to 4 days, but novel influenza viruses may have longer incubation periods, possibly up to 10 days. 6 A frequently updated report of countries that have had human infections with highly pathogenic H5N1 avian influenza viruses is available at the WHO Web website at http://www.who.int/csr/disease/avianinfluenza/en/. Individuals who handle or process animals with a novel virus, laboratory personnel who analyze specimens containing a novel virus and healthcare workers who care for patients infected with a novel virus are at risk for contracting that viral infection. If the virus of concern has not yet been shown to be capable of sustained human-to-human transmission, occupational risk would be higher for employees with exposure to animal or animal products. 6 [Table of Contents] Laboratory Diagnosis of Avian and Pandemic Influenza Currently, the highly pathogenic H5N1 avian influenza virus is considered to have the greatest potential for mutation to a pandemic virus given how widespread the virus is and because it has already caused illness and death in people. This virus has spread rapidly in bird populations throughout Asia, Europe, and Africa. Recently, HHS/CDC developed a 4-hour RT-PCR assay for the detection of the gene coding for the H5 surface protein of the Asian lineage of the highly pathogenic H5N1 avian influenza virus. 15 These RT-PCR reagents have been distributed to approximately 140 designated laboratories of the Laboratory Response Network (LRN) which has laboratories located in all 50 states. 15 The RT-PCR testing should be done when a patient has severe respiratory illness and clinical or epidemiological risk. Clinicians should contact their local or state health department as soon as possible to report any suspected human case of influenza H5N1 in the United States. Positive tests for influenza A H5N1 in the United States should be confirmed by HHS/CDC, which has been designated as a WHO H5 Reference laboratory. An HHS/CDC guidance document Updated Interim Guidance for Laboratory Testing of Persons with Suspected Infection with Avian Influenza A (H5N1) Virus in the United Statesis distributed via the Health Alert Network (HAN) at http://www2a.cdc.gov/han/ArchiveSys/ViewMsgV.asp?AlertNum=00246. Tests for other avian viruses with pandemic potential are also being developed. [Table of Contents] Modes of Transmission Information on the mode of seasonal influenza transmission is based on previous influenza outbreaks. However, the transmission characteristics of a pandemic influenza virus will not be known until after the pandemic begins. This section covers the transmission patterns of seasonal influenza and past and potential pandemic influenza outbreaks. [Table of Contents] Seasonal Influenza Transmission The usual method of seasonal influenza transmission is assumed to be through coughs and sneezes of infected persons within close proximity. A susceptible person may develop symptoms within 1 to 4 days after exposure to an infected patient who is shedding the influenza virus. The newly infected person is then infectious for about 6 days, usually beginning 1 day prior to the onset of symptoms. This varies with age and disease, as discussed previously. The relative importance of the various routes of transmission is not known, although it is now commonly accepted that the spread of seasonal influenza requires close proximity-via exposure to large droplets (droplet transmission), direct contact (contact transmission), or near range exposure to aerosols. 16 The term "near range" is used to differentiate influenza airborne transmission from the long-range airborne transmission seen in diseases such as tuberculosis, where disease spread can occur over long distances and prolonged periods of time. Droplet Transmission Epidemiologic patterns suggest that droplet transmission is a major route of influenza spread. Susceptible individuals are subject to infection by large particle droplets from infected patients. Droplets are produced by coughing, sneezing, or talking, or by therapeutic manipulations such as suctioning or bronchoscopy. Infected droplets may enter the susceptible individual through the conjunctiva of the eye or the mucus membranes of the mouth or nose. Droplets travel only about 3 feet and do not remain in the air, so special ventilation procedures and advanced respiratory protection is not required to prevent this type of transmission. 16 Airborne Transmission Airborne transmission, as occurs in tuberculosis, is spread through small infectious particles such as droplet nuclei. 17 Unlike the larger droplets, these very small airborne droplet nuclei can be readily disseminated by air currents to susceptible individuals. They can travel significant distances and can penetrate deep into the lung to the alveoli where they can establish an infection. The presence of significant airborne transmission would indicate the need for ventilation procedures and respiratory protection greater than that afforded by a surgical mask, e.g., a NIOSH-certified N95 or higher respirator. No study has definitively established airborne transmission as a major route of influenza transmission, but multiple studies suggest that some airborne influenza transmission may occur. Experiments in mice have demonstrated that air exchange can decrease influenza virus transmission, and have demonstrated infectious particles that are smaller than ten microns. 18 A ferret study demonstrated that influenza virus transmission can occur through a vent with right angles. A human volunteer study demonstrated that, when a small droplet aerosol is used, influenza transmission can occur with lower virus concentrations. 19 Another human observational study documented the spread of influenza to 72 percent of the passengers and crew on an airplane with a ventilation system that was not functioning for 3 hours. 20 While these studies suggest that airborne influenza transmission occurs under certain conditions, the proportion of influenza illness resulting from this route of transmission is unknown. Contact Transmission Contact transmission can be direct or indirect. Direct contact transmission occurs by touching skin to skin, usually during direct patient care activities such as turning or bathing patients, or by shaking hands. Indirect transmission occurs when infected material from the patient is deposited in the environment and is taken up by a susceptible individual. 16 There is limited data on the survivability of influenza A and B viruses outside of the human host. One study, 21 conducted by Bean et al., suggests that that if a heavily infected person contaminated a stainless steel surface, there might be enough viable viral particles remaining after 2-8 hours to allow contact transmission to a susceptible person. It should be noted that this study was conducted at a relative humidity of 35 to 40 percent, a level that favors the survival of influenza viruses. Other studies have clearly demonstrated that humidity plays a significant role in influenza viral survival with survival times being longer at lower humidity. Further research is needed to more fully appreciate the role of contact transmission for various strains of influenza and the effect of varying environmental conditions. Although it is assumed that influenza spreads by contact transmission, the proportion of spread that occurs through this mechanism is unknown. 16 [Table of Contents] Pandemic Influenza Transmission This section discusses observational studies on human-to-human transmission during previous influenza pandemics and observations about implications for transmission of current avian influenza virus infections that are of concern for possible future influenza pandemics. Transmission, Past Pandemics One influenza transmission study conducted during the 1957 pandemic indicated the importance of person-to-person spread while another suggested the apparent importance of airborne transmission. The first study, an epidemiological study demonstrated influenza transmission from a newly hospitalized, infected patient who had no isolation precautions to three healthcare workers and one adjacent patient. Ultimately, 30 of the 62 exposed patients and ward staff became ill. 22 Although the authors did not address the likely mode of transmission, a later analysis of the data was interpreted as not consistent with a single source pattern as would be seen in airborne transmission. 17 The second study, an observational influenza transmission study during the 1957 pandemic conducted at a Veterans Administration Hospital suggested airborne transmission. The study compared the influenza illness rates in tuberculosis patients in wards with and without ultraviolet ceiling lights and found rates of 2 percent and 19 percent, respectively. The authors of this study suggest this finding implies that transmission of influenza was significantly blocked by radiant (UV) disinfection of droplet nuclei. 23 Transmission, Possible Future Pandemics The influenza viruses that are currently of greatest concern for possible future pandemics are the highly pathogenic avian influenza viruses, most notably strains of H5N1 and H7N7, which have caused outbreaks among humans. A summary of the clinical features of hospitalized patients with highly pathogenic H5N1 avian influenza described a clinical course that differed from seasonal influenzas. The highly pathogenic H5N1 avian influenza had an initial presentation with lowerrespiratory tract symptoms and viral pneumonia (seasonal influenzas present more often with upper respiratory symptoms), a higher ribonucleic acid detection in pharyngeal samples (seasonal influenzas have higher viral detection in nasal samples), and more frequent diarrhea, abdominal pain, and vomiting. The detection of infectious virus and ribonucleic acid in the blood, cerebrospinal fluid (CSF) and feces of one patient, a child, 9 raises concern that transmission of this virus may be possible by contact with blood, CSF and feces in addition to respiratory secretions, but this remains unknown. An outbreak of highly pathogenic H7N7 avian influenza virus occurred in poultry farm employees in the Netherlands in 2003. 10 This influenza's clinical course was unique in that it was mainly associated with conjunctivitis. Seasonal influenza transmission is considered to take place primarily through the respiratory tract, but the conjunctivitis component of highly pathogenic H7N7 avian influenza suggests that its transmission may also occur via the mucous membranes of the eye. [Table of Contents] Treatment and Prevention Treatment and prevention of influenza involves multiple infection control measures, including vaccination, antiviral medications, and management of influenza complications. This section concentrates on immunization and antiviral medications. [Table of Contents] Seasonal Influenza Treatment and Prevention Medications available for influenza A treatment and prophylaxis include the M2 ion channel inhibitors (also known as adamantanes) amantadine and rimantadine and the neuraminidase inhibitors zanamivir and oseltamivir. Presently, only the neuraminidase inhibitors are available for treatment and prophylaxis of both influenza A and B. Current HHS/CDC drug recommendations, announced during the 2005-2006 influenza season (see http://www.cdc.gov/flu/han011406.htm), advise against the use of adamantanes for seasonal influenza due to resistance. Therefore, the neuraminidase inhibitors oseltamivir and zanamivir are the only drugs currently recommended for treatment and prophylaxis of influenza. Neuraminidase inhibitors are prescription drugs and they are most effective for treatment when use begins within two days of symptom onset. Clinicians should adhere to HHS/CDC recommendations regarding the use of antivirals. 24 Antiviral medications can be used to prevent influenza, but the primary strategy for preventing influenza infections is vaccination. Vaccines are available in two forms: 1) as an intranasal live attenuated vaccine and 2) as an injectable, inactivated trivalent vaccine. Indications and contraindications differ among the preparations. 25 Annual vaccination has been shown to reduce the incidence of influenza infections in healthcare workers. 25, 26, 27 Infection control measures are another means to prevent infection, but their benefit is less well established. [Table of Contents] Pandemic Influenza Treatment and Prevention The appropriate use of antiviral drugs during a pandemic could reduce mortality and morbidity. At the time of this writing, HHS recommendations for treatment of novel viruses are to use the neuraminidase inhibitors zanamivir and oseltamivir because of influenza resistance to amantadine and rimantadine. 24 Although the magnitude of drug effect against infections with novel strains cannot be predicted precisely, early use is expected to be important for drug effectiveness. The availability of adequate antiviral supplies during a pandemic is far from certain, and, therefore, the HHS Pandemic Influenza Plan provides antiviral drug use priority recommendations. Healthcare workers are included in the priority group recommendations. 28 A vaccine against a specific pandemic influenza strain will likely not be available until after the pandemic begins. But vaccinations against seasonal influenza during the WHO's Interpandemic and Pandemic Alert Period can reduce co-infections and might ameliorate pandemic effects. HHS recommendations are for enhanced levels of seasonal influenza vaccinations in groups at risk for severe influenza and healthcare workers. In addition, HHS recommends enhanced pneumococcal polysaccharide vaccination for some individuals. 29 A limited amount of H5N1 avian influenza vaccine is being stockpiled. However, as the pandemic virus cannot be predicted, it is unknown if stockpiled vaccine will provide protection against a future circulating pandemic influenza virus. A monovalent vaccine is expected to start becoming available within four-to-six months after identification of a specific pandemic virus strain. As noted above, the HHS Pandemic Influenza Plan recommends that health-care workers be included on the priority list (which has not been fully defined) when the availability of pandemic influenza vaccinations is limited. 28, 29 [Table of Contents] References
Infection Control A successful infection control program for pandemic influenza utilizes the same strategies implemented for any infectious agent, including facility and environmental controls (i.e., engineering controls), standard operating procedures (i.e., administrative controls), personal protective clothing and equipment, and safe work practices. These strategies form the basis of standard precautions and transmission-based precautions. Given that the exact transmission pattern or patterns will not be known until after the pandemic influenza virus emerges, transmission-based infection control strategies may have to be modified to include additional selections of engineering controls, personal protective equipment (PPE), administrative controls, and/or safe work practices. The infection control section of this document includes information about standard precautions and transmission-based precautions as they relate to the protection of healthcare workers. [Table of Contents] Standard Precautions and Transmission-Based Precautions Standard precautions are designed for the care of all patients, regardless of their diagnosis or presumed infection status. Transmission-based precautions are used for patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne, droplet, or contact transmission. Some infectious agents require the application of several types of precautions to prevent transmission. For example, HHS/CDC recommends that standard, contact, and airborne precautions be implemented when caring for patients with varicella infection. 1, 2 Initially designed for the hospital setting, standard precautions and transmission-based precautions can be applied to a variety of healthcare settings, including the outpatient environment, the pre-hospital setting, and alternate care sites. The infectious characteristics of pandemic influenza will not be known until after it emerges. Consequently, infection control plans will have to be adapted to the current knowledge of transmission and updated as new information becomes available. The Department of Health and Human Services (HHS) and its partners will provide updated epidemiologic information and infection control guidance at www.pandemicflu.gov. For a more complete discussion of standard precautions and transmission-based precautions, visit the HHS/CDC Guideline for Isolation Precautions in Hospitals website at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html. [Table of Contents] Standard Precautions Standard precautions should be used for all patients receiving care, regardless of their diagnosis or presumed infection status. Standard precautions apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin; and (4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in healthcare settings. A risk assessment to determine necessary PPE and work practices to avoid contact with blood, body fluids, excretions, and secretions will help to customize standard precautions to the healthcare setting of interest. Standard precautions include:
Implementation and enforcement of all standard precautions, including appropriate use of facial (eyes, nose, and mouth) protection when caring for respiratory patients, should be prioritized in all healthcare facilities in order to mitigate pandemic influenza transmission. [Table of Contents] Contact Precautions In addition to standard precautions, contact precautions are indicated for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. In addition to standard precautions, contact precautions include:
[Table of Contents] Droplet Precautions Droplet precautions are indicated for patients known or suspected to have serious illnesses transmitted by large particle droplets, such as seasonal influenza, invasive Haemophilus influenzae type b disease and invasive Neisseria meningitidis. In addition to standard precautions, droplet precautions include the use of a surgical mask when working within 3 feet of the patient and the placement of the patient in a private room or with patients who have an active infection with the same microorganism but with no other infection (cohorting). Although human seasonal influenza virus is transmitted primarily by contact with infectious droplets, some degree of airborne transmission occurs. Additionally, droplet precautions do not protect healthcare workers from infections resulting from aerosol transmission or during patient care activities that are likely to generate infectious aerosols, such as sputum induction or bronchoscopy. [Table of Contents] Airborne Precautions Airborne Precautions are designed to reduce the risk of airborne transmission of infectious agents. In addition to standard precautions, airborne precautions are used for patients known or suspected to have serious illnesses. Current clinical guidelines recommend that airborne precautions be used for such illnesses as H5N1 avian influenza, severe acute respiratory syndrome (SARS), measles, varicella, and tuberculosis. 1, 5, 6 Airborne precautions include:
For patients for whom influenza is suspected or diagnosed, surveillance, vaccination, antiviral agents, and use of private rooms as much as feasible is recommended. 7 In contrast to tuberculosis, measles, and varicella, the pattern of disease spread for seasonal influenza does not suggest transmission across long distances (e.g., through ventilation systems); therefore, negative pressure rooms are not needed for patients with seasonal influenza. 8 Many hospitals encounter logistic difficulties and physical limitations when admitting multiple patients with suspected influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very least, avoid room-sharing with high-risk patients. For additional information regarding the airborne infection isolation rooms, see the section Airborne Infection Isolation Rooms on page 19. [Table of Contents] Compliance with Infection Control Healthcare administrators should emphasize those aspects of infection control already identified as "weak links" in the chain of infectious precautions- adherence to hand hygiene, consistent and proper use of PPE, and influenza vaccination of healthcare workers. The following section describes factors influencing compliance with infection control measures. Healthcare employers and employees should work together address these factors and enhance compliance with infection control recommendations. [Table of Contents] Hand Hygiene Compliance Although handwashing is well known as a critical factor for infection control, low rates of healthcare worker compliance have been well documented. The HHS/CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), in collaboration with the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Infectious Diseases Society of America (IDSA) reviewed 33 studies from 1981 to 2000. They concluded that adherence of healthcare workers to recommended hand hygiene procedures has been poor, with mean baseline rates of 5 - 81 percent and an overall average of 40 percent. 3 Several factors influence adherence to hand hygiene practices, including
Appendix B contains extended information regarding risk factors for non-compliance with hand hygiene recommendations and strategies for successful promotion of hand hygiene. For a more complete discussion of the recommendations for hand hygiene and the scientific evidence, see the HHS/CDC Guideline for Hand Hygiene in Healthcare Settingsat http://www.cdc.gov/handhygiene/. [Table of Contents] Respiratory Protection Compliance Studies have shown that healthcare worker compliance rates with respiratory protection are highly variable. 9, 10 Healthcare workers fail to wear respirators for a number of reasons, and it is important to understand the nature of this resistance in order to overcome it. The following are the most frequently cited reasons for not wearing respirators: 11
Care Facilities, September 1999, accessible at http://www.cdc.gov/niosh/99-143.html. Initially intended for protection against tuberculosis, the guidance can be adapted to address a variety of infectious pathogens, including pandemic influenza. Healthcare employers should work hard to overcome employee resistance to wearing respirators and promote full compliance with the respiratory protection program. Strategies should be implemented to promote respirator use, such as staff education, reminders in the workplace and routine observation and feedback. [Table of Contents] Organizational Factors that Affect Adherence to Infection Control Lessons from the SARS outbreak showed that the most important factors affecting healthcare worker perceptions of risk and adherence to infection control practices were healthcare workers' perception that their facilities had clear policies and protocols, having adequate training in infection control procedures, and having specialists available. 12 In a study among 1,716 hospital-based healthcare workers, Gershon et al. (1995) found that employees who perceived a strong commitment to safety at their workplace were over 2.5 times more likely to comply with universal precautions. 13 Another study of nurses found that the perception of PPE interference with work was the strongest predictor of failure to comply with universal precautions. 14 The same researchers examined the relative importance of safety climate, the availability of PPE, and individual employee characteristics as determinants of compliance with universal precautions. Safety climate was found to have the greatest association with proper infection control behaviors. 15 Gershon et al. (2000) developed a safety climate scale (46 questions) to measure six different areas of a hospital safety climate:
[Table of Contents] Facility Design, Engineering, and Environmental Controls Engineering controls are the preferred method to reduce transmission of infectious aerosols in areas used to house or evaluate patients with respiratory illness. The appropriate use of engineering controls and other control efforts will require frequent analysis of pandemic influenza transmission patterns in designated wards, in the facility, and in the community. Existing healthcare facility layouts should be evaluated for potential enhancements of infection control. A SARS investigation in Ontario 17 noted that hospitals designed with open, public spaces encountered logistical difficulties and great expense in their efforts to control entry and, therefore, to control introduction of infectious diseases. Hospitals had an inadequate number of isolation rooms and negative pressure rooms. Triage areas were designed to streamline patient flow and enhance patient satisfaction, rather than to prioritize infection isolation or healthcare worker protection. A desirable emergency room design includes a triage area that can be closed off as an isolation area, in the event of inadvertent contamination. Isolation areas should have adjacent rooms for staff to put on and take off scrubs, and to take showers. Facility planning should include storage space for augmented infection control items, including durable goods such as ventilators, portable high-efficiency particulate air (HEPA) filtration units, portable x-ray units, and respirators. Thoughtful facility design includes rest and recuperation sites for responders. These sites can be stocked with healthy snacks and relaxation materials (e.g., music and movies), as well as pamphlets or notices about workforce support services. [Table of Contents] Facility Capacity An influenza pandemic may increase the demand for hospital inpatient and intensive care unit beds and assisted ventilation services by more than 25 percent. 18 Toronto clinicians reported that the intensive care unit capacity was a key factor that determined the number of SARS patients that could be managed. It was determined that approximately 20 percent of SARS patients required intensive care; therefore, a maximum number of SARS patients per facility could be calculated. 19 HHS/CDC provided instructions that allow public health officials to estimate the demand for hospital resources and to estimate the number of deaths, both for a 1968-type of influenza pandemic and for a 1918-type of pandemic. 20 FluAid 2.0 and FluSurge 2.0 software estimate the number of deaths, hospitalizations, outpatient visits, and the increased demand for hospital resources (e.g., beds, intensive care, or ventilators for both scenarios). For additional information see Appendix A. Alternate care sites may be developed at federal or state discretion to ease the burden of care on healthcare facilities. For additional information regarding alternate care sites, see section Alternate Care Sites on page 47. [Table of Contents] Engineering Controls in Improvised Settings Infectious disease and disaster management experts have predicted the need to use schools, stadiums, and other converted settings in the event of a pandemic that results in severe disease. The National Strategy for Pandemic Influenza 21 calls for communities to anticipate large-scale augmentation of existing healthcare facilities. During the SARS outbreak of 2004, the North York General Hospital in Toronto converted two nearly constructed hospital wings into SARS wards. Additionally, a tent clinic was built on an ambulance loading dock to triage the general public presenting with possible SARS. A more detailed description of the converted healthcare settings, including the implementation of engineering of controls, is available in Loutfy et al. 2004. 19 [Table of Contents] Airborne Infection Isolation Rooms Although the need to isolate patients with highly pathogenic infections is a central tenet of infection control, a large percentage of U.S. hospitals have no isolation rooms. Only 61.7 percent of hospitals responding to the American Hospital Association 2004 annual survey reported having an airborne infection isolation room. 22 Airborne infection isolation rooms receive numerous air changes per hour (ACH) (>12 ACH for new construction as of 2001; >6 ACH for construction before 2001), and is under negative pressure, such that the direction of the air flow is from the outside adjacent space (e.g., the corridor) into the room. The air in an airborne infection isolation room is preferably exhausted to the outside, but may be recirculated provided that the return air is filtered through a high-efficiency particulate air (HEPA) filter. For more information, consult the HHS/CDC Guidelines for Environmental Infection Control in Health Care Facilities, available at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html. For care of pandemic influenza patients in the hospital: 4
Engineering Controls for Aerosol-Generating Procedures for Patients with Pandemic Influenza If possible, and when practical, use of an airborne isolation room may be considered when conducting aerosol-generating procedures, 4, 6 such as the following:
Cohorting If single rooms are not available, patients infected with the same organisms can be cohorted (share rooms). These rooms should be in a well-defined area that is clearly separated from other patient care areas used for uninfected patients. During a pandemic, other respiratory viruses (e.g., non-pandemic influenza, respiratory syncytial virus, parainfluenza virus) may be circulating concurrently in a community. Therefore, to prevent cross-transmission of respiratory viruses, whenever possible assign only patients with confirmed pandemic influenza to the same room. Management of cohort areas should incorporate the following: 4
Engineering Controls in Diagnostic and Research Laboratories During the Pandemic Alert Period, specimens from suspected cases of human infection with novel influenza viruses should be sent for testing to public health laboratories with proper biocontainment facilities. For example, reverse transcriptase polymerase chain reaction (RT-PCR) can be done in a Biosafety Level 2 laboratory but highly pathogenic avian influenza and highly pathogenic pandemic influenza virus isolation should be conducted in a Biosafety Level 3 laboratory with enhancements or higher as dictated by an appropriate risk assessment. Additional information on laboratory biocontainment is provided in the HHS publication Biosafety in Microbiological and Biomedical Laboratories. 25 Pneumatic tube systems are not advisable to transport specimens that may contain a highly pathogenic, live virus. Guidelines on when to send specimens or isolates of suspected novel avian or human strains to HHS/CDC for reference testing are available in Appendix 3 of the HHS Pandemic Influenza Planat http://www.hhs.gov/pandemicflu/plan/sup2.html#app3. 26 The American Society for Microbiology maintains a list of emergency contacts in state public health laboratories. 27 [Table of Contents] Autopsy Rooms for Cases of Pandemic Influenza Safety procedures for pandemic influenza-infected human bodies should be consistent with those used for any autopsy procedure with potentially infected remains. In general, the hazards of working in the autopsy room seem to depend more on contact with infected material, particularly with splashes on body surfaces, than to inhalation of infectious material. However, if the pandemic influenza-infected patient died during the infectious period, the lungs may still contain virus and additional respiratory protection is needed during procedures performed on the lungs or during procedures that generate small-particle aerosols (e.g., use of power saws and washing intestines). Protective autopsy settings for pandemic influenza-infected humans include the use of an airborne infection isolation room (see the section Airborne Infection Isolation Rooms on page 19). Exhaust systems around the autopsy table should direct air (and aerosols) away from healthcare workers performing the procedure (e.g., exhaust downward). It is important to use containment devices whenever possible (e.g., biosafety cabinets for the handling of smaller specimens). Therefore, an examiner conducting postmortem exams of pandemic influenza-infected patients will use airborne precautions, including a particulate respirator, as is recommended for postmortem exams of avian influenza-infected patients and SARS-infected patients. 28 [Table of Contents] Administrative Controls Respiratory Hygiene/Cough Etiquette Respiratory hygiene/cough etiquette, procedures should be used for all patients with respiratory symptoms (e.g., coughing and sneezing). The impact of covering coughs and sneezes and placing a mask on a coughing/sneezing patient on the containment of respiratory droplets and secretions or on the transmission of respiratory infections has not been quantified. However, any measure that limits the dispersion of respiratory droplets should reduce the opportunity for transmission. Masking some patients may be difficult, in which case the emphasis should be on cough etiquette. The elements of cough etiquette are listed below. For additional information, see Respiratory Hygiene/Cough Etiquette in Healthcare Settings at http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm. [Table of Contents] Pandemic Influenza Specimen Collection and Transport All human specimens of secretions and excretions should be regarded as potentially infectious. Healthcare workers who collect or transport clinical specimens should consistently adhere to recommended infection control precautions to minimize their exposure. Potentially infectious specimens should be placed in leakproof specimen bags for transport, labeled or color coded for transport and handled by personnel who are familiar with safe handling practices and spill clean-up procedures. Healthcare workers who collect specimens from pandemic-infected patients should also wear PPE as described for employees performing direct patient care. Specimens should be hand delivered where possible. Pneumatic tube systems are not advisable to transport specimens that may contain a highly pathogenic, live virus. For additional information about specimen collection, visit WHO's website at http://www.who.int/csr/disease/avian_influenza/guidelines/humanspecimens/en/index.html. [Table of Contents] Patient Transport within Healthcare Facilities Influenza-infected patients' respiratory secretions are the principle source of infectious material in healthcare settings. Maintaining source control of patient secretions will limit the opportunities for nosocomial (in hospital) transmission. The following methods of source control are consistent with those recommended for other serious respiratory infections (e.g., SARS, avian influenza, and tuberculosis. 4, 28, 29
Pre-Hospital Care and Patient Transport Outside Healthcare Facilities During an influenza pandemic, patients will still require emergency transport to a healthcare facility. The recommendations in the table on page 23 are designed to protect healthcare workers, including emergency medical services personnel, during pre-hospital care and transport. These recommendations can be instituted when patients are identified as having symptoms consistent with an influenza-like illness or routinely, regardless of symptoms, when pandemic influenza is in the community. [Table of Contents] Staff Education and Training It is incumbent upon healthcare employers to educate employees about the hazards to which they are exposed and to provide reasonable means by which to abate those hazards. The independent SARS Commission established by the government of Ontario noted that many healthcare staff were not adequately trained in protecting themselves against infectious agents. The Commission noted deficiencies in safety training and the proper use of personal protective equipment. 30 Effective staff training is consistent with facility policies and reinforces infection control strategies. Support from the healthcare institution at the top management and supervisory levels is essential for a successful program. Examples of educational goals and objectives for pandemic infection control strategies include:
|