Frequently Asked Questions on Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers
This document provides general information regarding OSHA's Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers (OSHA Publication 3328) and links to additional resources. Page numbers are given for sections of the longer document that address the question asked.
Question 1: Is an influenza pandemic expected to occur? (pp. 5 & 8)
Many scientists believe that since no pandemic has occurred since 1968, it is only a matter of time before another pandemic occurs. 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.
Question 2: How will I know when an influenza pandemic has started? (pp. 8 & 36)
The World Health Organization (WHO) maintains a global surveillance system of circulating influenza strains and a Global Influenza Preparedness Plan. 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"). In the event of a pandemic, the U.S. Department of Health and Human Services (HHS)/Centers for Disease Control and Prevention (CDC) will coordinate support and intelligence with U.S. public health departments regarding the pandemic situation in the U.S. and in foreign countries.
Question 3: What are some recommended precautions for the protection of healthcare workers during an influenza pandemic? (pp. 7-33)
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 following precautions are advisable until more information is known about the transmission of any future pandemic influenza virus.
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.
If possible, and when practical, use of an airborne infection isolation room may be considered when conducting aerosol-generating procedures. Airborne infection isolation rooms receive numerous air changes per hour and are under negative pressure, so 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.
Cohorting: If single rooms are not available, patients infected with the same organisms can be cohorted (share rooms). Management of cohort areas should incorporate the following:
- Whenever possible, healthcare workers assigned to cohorted patient care units should be experienced healthcare workers and should not "float" or be assigned to other patient care areas.
- The number of persons entering the cohorted area should be limited to the minimum number necessary for patient care and support.
- Limit patient transport by having portable x-ray equipment available in cohort areas.
Administrative Controls/Work Practices
Hand Hygiene: To reduce the risk of becoming infected with influenza, healthcare workers working with influenza patients should follow rigorous hand hygiene measures:
- When hands are visibly dirty or contaminated with respiratory secretions, wash hands with soap (either non-antimicrobial or antimicrobial) and water.
- If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations including contact, whether gloved or ungloved, with an influenza patient.
- Hand hygiene before and after patient contact, and after removing gloves and other PPE.
Facility Hygiene: To protect healthcare workers, standard practices for handling and reprocessing used patient care equipment, including medical devices, should be followed.
- Healthcare workers should wear gloves when handling and transporting used patient care equipment.
- Healthcare workers should wipe heavily soiled equipment with a U.S. Environmental Protection Agency (EPA)-approved hospital disinfectant before removing it from the patient’s room and follow current recommendations for cleaning and disinfection or sterilization of reusable patient care equipment.
- Healthcare workers should wipe external surfaces of portable equipment (e.g., for performing x-rays and other procedures) in the patient’s room with an EPA-approved hospital disinfectant upon removal from the patient's room.
Healthcare workers should use precautions when cleaning the rooms of pandemic influenza patients or of influenza patients who have been discharged or transferred.
Cleaning and Disinfection of Patient-Occupied Rooms:
- Wear gloves in accordance with facility policies for environmental cleaning.
- Wear a surgical mask in accordance with droplet precautions. Use a respirator when airborne precautions are warranted by the circumstances.
- Gowns are usually not necessary for routine cleaning of an influenza patient's room. However, a gown must be worn when cleaning a patient's room if soiling of the employee's clothes or uniform with blood or other potentially infectious materials may occur.
- Wear face and eye protection if cleaning within 6 feet of a coughing patient.1
- Keep areas within 6 feet of the patient free of unnecessary supplies and equipment to facilitate daily cleaning.
- Use any EPA-registered hospital detergent-disinfectant.
- Give special attention to frequently touched surfaces (e.g., bedrails, bedside and over-bed tables, TV controls, call buttons, telephones, lavatory surfaces including safety/pull-up bars, doorknobs, commodes, and ventilator surfaces) in addition to floors and other horizontal surfaces.
Cleaning and Disinfection after Patient Discharge or Transfer:
- Follow standard facility procedures for post-discharge cleaning of an isolation room.
- Clean and disinfect all surfaces that were in contact with the patient or might have become contaminated during patient care.
Respiratory Hygiene/Cough Etiquette: Educate persons with respiratory illness and coughing or sneezing to:
- Cover their mouths and noses with a tissue and dispose of used tissues in no-touch waste containers.
- Use a mask when tolerated, especially during periods of increased respiratory infection activity in the community.
- Perform hand hygiene after contact with respiratory secretions and contaminated objects or materials (e.g., handwashing with soap and water, alcohol-based hand rub, or antiseptic handwash).
- Stand or sit at least 6 feet from other persons, if possible.
For additional information, see Respiratory Hygiene/Cough Etiquette in Healthcare Settings.
Precautions during Specimen Collection and Transport: 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 cleanup procedures. Healthcare workers who collect specimens from pandemic-influenza infected patients should also wear PPE as described for employees performing direct patient care.
Precautions during 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.
- Surgical and procedure masks are appropriate for use by pandemic influenza-infected patients to contain respiratory droplets and should be worn by suspected or confirmed pandemic influenza-infected patients during transport or when care is necessary outside of the isolation room area.
- Limit the movement and transport of patients from the isolation room/area for essential purposes only. Inform the receiving area/facility as soon as possible, prior to the patient’s arrival, of the patient's diagnosis and of the precautions that are indicated. Use mobile diagnostic services (e.g., mobile X-ray and CT scan) when available.
- If transport outside the isolation room is required, the patient should wear a surgical mask and perform hand hygiene after contact with respiratory secretions.
- If the patient cannot tolerate a mask (e.g., due to the patient’s age or deteriorating respiratory status), instruct the patient (or parent of pediatric patient) to cover the nose and mouth with a tissue during coughing and sneezing, or use the most practical alternative to contain respiratory secretions. If possible, instruct the patient to perform hand hygiene after respiratory hygiene.
- Identify appropriate paths, separated from the main traffic routes as much as possible, for entry and movement of pandemic influenza patients in the facility, and determine how these pathways will be controlled (e.g., dedicated pandemic influenza corridors and elevators).
- If there is patient contact with surfaces, these surfaces should be cleaned and disinfected.
- Healthcare workers transporting unmasked patients with suspected or confirmed pandemic influenza-infected patients should wear an N95 or higher NIOSH-certified respirator.
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.
Personal Protective Equipment (PPE)
Gloves: HHS recommends the use of gloves made of latex, vinyl, nitrile, or other synthetic materials as appropriate, when there is contact with blood and other bodily fluids, including respiratory secretions.
- There is no need to double-glove.
- Gloves should be removed and discarded after patient care.
- Gloves should not be washed or reused.
- Hand hygiene should be done after glove removal.
- Healthcare workers should wear an isolation gown when it is anticipated that soiling of clothes or uniform with blood or other bodily fluids, including respiratory secretions, may occur. HHS states that most routine pandemic influenza patient encounters do not necessitate the use of gowns. Examples of when a gown may be needed include procedures such as intubation or when closely holding a pediatric patient.
- Isolation gowns can be disposable and made of synthetic material or reusable and made of washable cloth.
- Gowns should be the appropriate size to fully cover the areas requiring protection.
- After patient care is performed, the gown should be removed and placed in a laundry receptacle or waste container, as appropriate. Hand hygiene should follow.
Goggles/Face Shields: The HHS Pandemic Influenza Plan does not recommend the use of goggles or face shields for routine contact with patients with pandemic influenza; however, if sprays or splatters of infectious material are likely, it states that goggles or a face shield should be worn as recommended for standard precautions. If a pandemic influenza patient is coughing, any healthcare worker who needs to be within 6 feet of the infected patient is likely to encounter sprays of infectious material. Eye and face protection should be used in this situation, as well as during the performance of aerosol-generating procedures.
For additional information about eye protection for infection control, see NIOSH's Eye Protection for Infection Control.
Respiratory Protection for Pandemic Influenza: While droplet transmission is likely to be the major route of exposure for pandemic influenza, as is the case with seasonal influenza, it may not be the only route. Given the potential severity of health consequences (illness and death) associated with pandemic influenza, a comprehensive influenza preparedness plan should address airborne transmission to ensure that healthcare workers are protected against all potential routes of exposure.
More information on the elements of a comprehensive respiratory protection program and the use of respirators can be found in the Respiratory Protection Safety and Health Topics Page.
Respirators: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer's risk of inhaling hazardous gases, vapors, or airborne particles (e.g., dust or droplet nuclei containing infectious agents).
- A type of respirator commonly found in healthcare workplaces is the filtering facepiece respirator (often referred to as an "N95"). It is designed to protect against particulate hazards. Since airborne biological agents such as bacteria or viruses are particles, they can be filtered by particulate respirators. To assure a consistent level of performance, the respirator's filtering efficiency is tested and certified by NIOSH.
- Respirator filters that remove at least 95 percent of airborne particles, during "worst case" testing using the "most-penetrating" size of particle, are given a 95 rating. Recent HHS/CDC infection control guidance documents provide recommendations that healthcare workers protect themselves from diseases potentially spread through the air by wearing a fit tested respirator at least as protective as a NIOSH-certified N95 respirator.
- Once worn in the presence of an infectious patient, the respirator should be considered potentially contaminated with infectious material, and touching the outside of the device should be avoided. Upon leaving the patient's room, the disposable respirator should be removed and discarded, followed by proper hand hygiene.
- If a sufficient supply of respirators is not available during a pandemic, healthcare facilities may consider reuse as long as the device has not been obviously soiled or damaged (e.g., creased or torn), and it retains its ability to function properly.
- If disposable respirators need to be reused by an individual user after caring for infectious patients, employers should implement a procedure for safe reuse to prevent contamination through contact with infectious materials on the outside of the respirator.
- Powered air-purifying respirators use HEPA filters which are as efficient as P100 filters and will protect against airborne infectious agents. Powered air-purifying respirators provide a higher level of protection than disposable respirators. Healthcare facilities have used higher levels of respiratory protection, including powered air-purifying respirators, for persons present during aerosol-generating medical procedures, such as bronchoscopy, on patients with infectious pulmonary diseases.
- Although some disposable respirators look similar to surgical masks, it is important that healthcare workers understand the significant functional difference between disposable respirators and surgical masks.
- Surgical masks are not designed to prevent inhalation of airborne contaminants.
- Surgical masks are not considered adequate respiratory protection for airborne transmission of pandemic influenza.
- Surgical masks are also used as a physical barrier to protect the healthcare worker from hazards such as splashes of blood or bodily fluids.
- When both fluid protection (e.g., blood splashes) and respiratory protection are needed, a "surgical N95" respirator can be used. This respirator is approved by FDA and certified by NIOSH.
For a more complete discussion of respirator use during an influenza pandemic, see the section titled "Respiratory Protection for Pandemic Influenza" that begins on page 27 of OSHA Publication 3328
Correctly Putting On and Removing PPE: When PPE is necessary for the specific situation, HHS/CDC recommends that personal protective equipment be put on in the following order:
- Respirator (or mask, when appropriate)
- Face shield or goggles
Upon leaving the room, HHS/CDC recommends that PPE be removed in a way to avoid self-contamination, as follows:
- Faceshield or goggles
- Respirator or mask
Remember to always use hand hygiene after removing PPE. A printable poster on the sequences for putting on and taking off PPE, which can be used for employee training and can be posted outside respiratory isolation rooms is available, see NIOSH's Severe Acute Respiratory Syndrome (SARS): Infection Control.
Question 4: Will my employer be able to provide shots to protect me from pandemic influenza? (p. 13)
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. A monovalent vaccine is expected to start becoming available within four-to-six months after identification of a specific pandemic virus strain.
The HHS Pandemic Influenza Plan recommends that healthcare workers be included on the priority list when the availability of pandemic influenza vaccinations is limited.2
Question 5: How can I protect my coworkers and help prevent transmission of pandemic influenza within the healthcare facility? (p. 17)
Healthcare employers and employees should work together to develop an institutional safety climate that encourages compliance with recommended infection control practices. 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.3
Question 6: How do I protect my family?
A Guide for Individuals and Families, a checklist, and forms for family health information to help guide your planning and preparation are available, see Pandemic Influenza Planning: A Guide for Individuals and Families.
Question 7: What else can I do to prepare?
Visit: One-stop access to U.S.government avian and pandemic flu information, managed by the Department of Health and Human Services.
1 Infection control professionals have traditionally used a range of 3-6 feet to reflect the distance from a patient that potentially infectious particles could travel. Recent reviews of the scientific literature suggest that the data on what constitutes "close contact" is not definitive. For pandemic influenza planning purposes, and in order to be more protective, DOL and HHS experts now recommend that close contact be considered a distance of less than 6 feet.
2 The DHHS/DHS Pandemic Influenza Vaccine Allocation and Targeting Guidance was released in August 2008.
3 For guidance on when to stay home and when to return to work, see the Department of Veterans Affairs When to return to Your Workplace or to School.