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Last Updated: February 8, 2010

Employer Guidance: Reducing Healthcare Workers' Exposures to the 2009 H1N1 Virus


As new information about the 2009 H1N1 virus becomes available, this workplace guidance will be reevaluated and updated. Employers and workers should review OSHA's Workplace Safety and H1N1 often to ensure they have the most up-to-date information when making decisions about their current operations and planning.

Introduction
There are ways to protect someone who works closely with people who are or may be infected with 2009 H1N1 flu. This page informs employers and managers on ways to protect workers who carry out tasks and activities that require close contact with patients who have or may have 2009 H1N1 flu, specimens from these patients, and contaminated materials. These workers perform tasks such as direct patient care, aerosol-generating procedures, specimen analysis, and other types of direct care and patient support, like dietary and housekeeping services. These tasks can be performed in various settings such as inpatient and outpatient facilities, home healthcare settings, and health services in institutional settings like schools and correctional facilities. Workers who perform these tasks are at a higher risk of exposure to the 2009 H1N1 virus and so need additional precautions to protect them in the workplace.

Review your pandemic flu plan and make sure it covers the precautions highlighted in this page. If you don't have a plan, use OSHA's Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers and HHS/CDC's healthcare planning resources and this page to develop one. Healthcare employers need to use a combination of controls to protect workers and help reduce the transmission of 2009 H1N1 virus, including: 
  • encouraging sick workers to stay at home

  • emphasizing hand hygiene and cough etiquette

  • promoting vaccination

  • using airborne infection isolation rooms and other workplace controls

  • limiting patient transport and using other work practices, and

  • providing and ensuring the use of appropriate personal protective equipment.
When workplace controls are not feasible or are not enough to protect workers, employers must provide appropriate personal protective equipment and ensure its use. For job tasks where close contact with 2009 H1N1 flu patients cannot otherwise be eliminated, HHS/CDC recommends the use of a fit-tested N95 disposable respirator or better for healthcare personnel whose job duties require them to be in close contact (within 6 feet or entering into a small enclosed airspace (e.g., average patient room) shared with the patient) with confirmed or suspected 2009 H1N1 flu patients and for personnel performing high-risk aerosol-generating procedures on such patients. Employers who require workers to wear respiratory protection (including N95 disposable respirators or better) must have a complete respiratory protection program in place in accordance with 29 CFR 1910.134. The demand for disposable respirators may exceed available supplies during the 2009-2010 flu season. It is critical that employers make a good faith effort to obtain respirators and use all available means to maximize the availability of respiratory protection. Additional information about respirator use and assigning priorities is included below and on the HHS/CDC 2009 H1N1 website.

Basic Precautions for All Work Activities
H1N1 Flu - Self-EvaluationEncourage Sick Workers to Stay Home
  • Encourage sick workers to stay home. The HHS/CDC recommends that workers who have a fever or chills and a cough or sore throat stay at home until 24 hours after their fever ends (defined as 100 degrees Fahrenheit [37.8 degrees Celsius]), without the use of medication. Not everyone who has 2009 H1N1 flu will have a fever. Other symptoms could include a runny nose, body aches, headache, tiredness, diarrhea, or vomiting.

  • Discuss with staff leave, pay, transportation, travel, childcare, absence and other human resources policies. Develop non-punitive flexible leave policies that encourage workers to stay home if they are sick.
Develop a Policy for Ill Workers and Consider Additional Medical Surveillance and Screening Woman sneezing into a tissue Promote Hand Hygiene and Cough Etiquette
  • Useful resource: HHS/CDC provides "Germ Stopper" posters that can be posted in the workplace to reinforce basic hygiene practices.
  • Useful resource: HHS/CDC resources on hand washing.
  • Workers, patients, and visitors should use proper hand hygiene and cough etiquette

  • Workers, patients, and visitors, should have easy access to supplies such as:

    • "No touch" wastebaskets for used tissues;

    • Soap and water;
      Washing hands
    • Alcohol-based hand rubs;

    • Disposable towels;

    • Cleaning and sanitation materials.

  • Lobbies, halls, and restrooms should have the above items and workers should know the location.
Hand Hygiene

Wash hands after blowing your nose, coughing, sneezing, or coming into contact with mucus or contaminated objects and surfaces.

Wash hands after all patient contacts, contact with respiratory secretions, and before putting on and upon removing personal protective equipment.

Soap and water: rub soapy hands together for at least 20 seconds, rinse hands with water and dry completely.

Alcohol-based hand rubs: If soap and water are not available, use of an alcohol-based hand rub may be helpful as an interium measure until hand washing is possible. When using an alcohol-based hand rub, apply liquid to palm of hand, cover all surfaces of the hands with the liquid, and rub hands together until dry.

Wash your hands after shaking hands with another person.

Even if you use gloves, wash your hands after you have removed them in case your hand(s) became contaminated when you removed them.
Cough Etiquette

Cover coughs and sneezes with a tissue, or cough and sneeze into your upper sleeve(s).

Dispose of used tissues in "no touch" wastebaskets.
Vaccine
Encourage Workers to Get Vaccinated
  • The HHS/CDC strongly recommends that you provide both the seasonal and the 2009 H1N1 vaccine to healthcare workers and encourage workers to get vaccinated. Healthcare and emergency medical services personnel are a priority group for receiving the 2009 H1N1 flu vaccine. For additional information about seasonal flu vaccine priorities, see Key Facts About Seasonal Flu Vaccine. For information about 2009 H1N1 vaccine priorities, see 2009 H1N1 Vaccination Recommendations.


Additional Controls for Healthcare Activities
Workers who treat 2009 H1N1 flu patients, and workers who deal with contaminated materials and lab specimens from these patients require additional precautions. These include workplace controls, work practices, and personal protective equipment (PPE). Workplace controls are the most effective means for reducing exposure and should be considered first. PPE is the least effective means for reducing exposure and should be considered only when close contact cannot be otherwise eliminated using other means. HHS/CDC has developed specific guidance for the healthcare setting about how to implement the controls listed below for the 2009 H1N1 virus.

Install Physical Barriers, Isolate 2009 H1N1 Flu Patients, and Use Other Workplace Controls
  • Install sneeze guards or reception windows at intake areas, partitions in triage areas, and other barriers between workers and the general public.

  • Where possible, rearrange or reorient service areas and workspaces so that workers are separated from coworkers, patients, visitors and the general public by a distance of at least 6 feet.

  • Place patients who have or may have 2009 H1N1 flu in individual rooms with the doors closed.

  • If single rooms are not available, patients who are infected with the same organism can be cohorted (share rooms).

  • Allow only those staff who are essential for patient care and support into patient isolation rooms.

  • Use portable HEPA filtration units to help reduce the concentration of contaminants in patient isolation room air.

  • Use patient isolation rooms with a hand washing sink, toilet and bath facilities.

  • Where possible, use Airborne Infection Isolation rooms when performing aerosol-generating procedures such as:

    • Bronchoscopy

    • Sputum induction

    • Endotracheal intubation and extubation

    • Open suctioning of airways

    • Cardiopulmonary resuscitation

    • Autopsies (during certain procedures)

  • Perform aerosol-generating procedures on patients who have or may have 2009 H1N1 flu only if medically necessary.

  • Exclude unprotected workers from rooms where aerosol-generating procedure have been conducted until sufficient time has passed to remove potentially infectious particles through air changes and normal air mixing. For more information on air clearance rates, see Table 1 (Air changes per hour (ACH) and time required for removal efficiencies of 99% and 99.9% of airborne contaminants) of the Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005 document.

  • Provide dedicated patient care equipment for 2009 H1N1 flu patients.

  • Use the appropriate Biosafety Level (2 in laboratory facilities that handle specimens from 2009 H1N1 flu patients.

  • If available, use closed suctioning systems and high quality filters on the expiratory ports of ventilators.
Control Workplace Access
  • Limit access to the workplace by the general public, or ensure that they can only enter designated areas.

  • Enhance security policies and procedures to control access to the workplace.

  • Establish methods to screen patients for flu-like symptoms at every point of entry to the facility.

  • Develop and publicize workplace visitation policies and procedures.
Reduce Patient Transport and Use Other Work Practices
  • Limit patient transport. Conduct exams at the bedside instead of transporting the patient. Place a face mask on ill patients, if tolerated, when outside of their rooms.

  • Share information about patients who have or may have 2009 H1N1 flu with appropriate personnel before transferring them to other departments and other facilities.

  • Where possible, expand Internet and phone-based client service to minimize face-to-face contact.

  • Perform maintenance, cleaning and other services when staffing levels and patient movement are reduced.
Dealing with Respirator Shortages

OSHA Statement re: H1N1-related Inspections
The demand for disposable respirators may exceed available supplies during the 2009-2010 flu season. It is critical that employers make a good faith effort to obtain respirators and use all available means to maximize the availability of respiratory protection. Consider the following:
    • clearly identify and communicate to workers which tasks require the use of respiratory protection;

    • reduce the number of workers who need to use respiratory protection by using the workplace controls and work practices identified above;

    • substitute alternatives to N95 disposable respirators (more protective disposable respirators, elastomeric tight-fitting respirators, and powered air-purifying respirators (PAPRs)

    • extend the use of or reuse N95 disposable respirators, and

    • prioritize the use of N95 disposable respirators.
Additional information about respirator use and assigning priorities is posted on the HHS/CDC 2009 H1N1 website.
Provide Respiratory Protection
  • When workplace controls and work practices are not feasible or are not enough to protect workers, employers must provide appropriate personal protective equipment and ensure its proper use. HHS/CDC recommends the use of a fit-tested N95 disposable respirator or better for healthcare personnel whose job duties require them to be in close contact (within 6 feet or entering into a small enclosed airspace (e.g., average patient room) shared with the patient) with confirmed or suspected 2009 H1N1 flu patients and for personnel performing high-risk aerosol-generating procedures on such patients.

  • Employers who have workers wearing respiratory protection (including N95 disposable respirators) must have a complete written respiratory protection program in place in accordance with OSHA's Respiratory Protection standard, 29 CFR 1910.134 including medical evaluations, training and fit testing when respirator use is necessary.

  • Identify how respirator use will be prioritized in your workplace if a severe shortage exists.

  • Ensure that respirators are always available where exposure to the 2009 H1N1 virus is the highest, such as aerosol–generating activities.

  • Consider the management of patients with non-flu diseases that require respiratory protection (e.g., tuberculosis) and maintain an emergency reserve for unforeseen situations.

  • Workers who provide care to 2009 H1N1 patients and who are not provided N95 disposable respirators due to prioritized use should be provided with surgical masks.

  • See OSHA's Informational videos on N95 respirator safety[English] [En Español] and on the difference between an N95 respirator and a surgical mask [English] [En Español]

  • Additional information about respirator use and assigning priorities is posted on the HHS/CDC 2009 H1N1 website.

  • See the NIOSH Trusted-Source page to verify which respirators are approved by NIOSH, and for more information about how to get and use NIOSH-approved respirators.
Provide Other Personal Protective Equipment
  • Provide gloves made of nonpowered latex, vinyl, nitrile, or other synthetic materials, as appropriate, for potential contact with blood, respiratory secretions, and other bodily fluids.

  • Provide eye and face protection if sprays or splatters of infectious material are likely.

    • Goggles should be worn while performing aerosol-generating procedures.

    • Use a full face shield in front of a respirator to prevent contamination.

  • Provide protective clothing (e.g., isolation gowns) when soiling clothes with blood, respiratory secretions or other bodily fluids is possible.

    • After use, place the clothing in a no-touch laundry receptacle or wastebasket.

    • Wash hands after removing protective clothing.

  • Provide PPE for other workplace hazards, such as bloodborne pathogens, hazardous chemicals and physical agents.

  • Train workers to put on (don) and take off (doff) PPE in the proper sequence to avoid accidental self-contamination.

  • Ensure that PPE is used, maintained and discarded correctly.
Keep the Workplace Clean
  • Routine cleaning and disinfection methods used during flu season should be applied during the 2009 H1N1 flu.

  • Manage laundry, utensils and medical wastes using the same procedures as for seasonal flu.

  • Keep common, frequently touched work surfaces, work areas, and equipment (e.g., doorknobs, lunch areas, copiers, etc.) clean.

    • Useful Resource: EPA's website has information on registered flu disinfectants.
    Provide disinfectants and disposable towels for workers to use to clean their work spaces and surfaces, and to keep work areas clean.
Post Signs
  • Post signs on doors to rooms of any patients with the 2009 H1N1 flu stating the precautions required for entry.

     
    • Useful resource: HHS/CDC provides "Germ Stopper" posters that can be posted in the workplace to reinforce basic hygiene practices.
    • Useful resource: HHS/CDC resources on hand washing.
  • Post signs at entry points instructing patients and family members about hospital policies such as:

    • Asking family members to avoid visiting if they are not seeking medical treatment.

    • Asking patients and family members to report symptoms of a respiratory illness when they arrive at the facility.

  • Post signs encouraging proper hand hygiene and cough etiquette.

Educate Workers About Conditions That Place Them at Higher Risk for Complications of Flu
  • HHS/CDC has identified groups of individuals that have a higher risk for complications from 2009 H1N1 flu (e.g., pregnant women, persons with asthma, etc.).

  • Inform workers that some people are at higher risk of complications from the flu and suggest that they talk with their doctor about their own risk and what to do if they become ill.

  • Consider offering alternative work environments to accommodate workers at higher risk for complications of flu during periods of increased flu activity or if flu severity increases.
Prepare for Possible School Closures or Suspension of Child Care ProgramsPhysician with stethoscope and young boy

For more information, see OSHA’s Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers. OSHA Publication No. 3328, which can be accessed at www.osha.gov. Also see HHS/CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel.
This guidance is not a standard or regulation, and it creates no new legal obligations. It contains recommendations as well as descriptions of mandatory safety and health standards. The recommendations are advisory in nature, informational in content, and are intended to assist employers in providing a safe and healthful workplace. The Occupational Safety and Health Act requires employers to comply with safety and health standards and regulations promulgated by OSHA or by a state with an OSHA-approved state plan. In addition, the Act's General Duty Clause, Section 5(a)(1), requires employers to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.