Pandemic Flu:Protecting Employees in Non-

Health Care Environments

5-27-2009Deborah Gold, MPH, CIH,

dgold@hq.dir.ca.govSenior Safety Engineer Cal/OSHA

Swine Flu2009 Influenza A H1N1 SOI

• Apparently started in Mexico, originally 150 deaths reported, now WHO reports 83 deaths out of 4541 confirmed cases

• U.S., 6764 cases, 10 deaths (confirmed)

• 921 cases Canada

• Also numerous cases in Spain, Japan, UK

  Week 19

No. of specimens tested 7,127

No. of positive specimens (%) 1,074 (15.1%)

Positive specimens by type/subtype  

Influenza A 1,026 (95.5%)

A (H1) 66 (6.4%)

A (H3) 80 (7.8%)

A (unsubtyped) 101 (9.8%)

A (could not be subtyped) 37 (3.6%)

A (novel influenza H1N1) 742 (72.3%)

Influenza B 48 (4.5%)

Source: CDC, http://www.cdc.gov/flu/weekly/

U.S. Laboratory Confirmed Influenza Cases

(Week Ending May 16)

http://www.who.int/csr/don/2009_05_27a/en/index.html

Non-infection Impacts on Health and Safety

• Employee absences and changes in commerce may result in reassignment of employees– may require additional training for employees

and supervisors not accustomed to tasks– School closures

• Disruption of supplies– Supplies used in general industry, such as

respirators, gloves, towels, etc. may be in short supply

Continuing H1N1 Concerns

• Virus is circulating in various countries

• At least one case of probable human to animal transmission (Canadian)

• Potential for mixing with other influenza viruses

• Will it impact fall flu season (e.g. 1918)?

OSHA Risk Pyramid

HCW – Aerosol Generating Procedures

HCW

High Frequency Contact with General Population

Minimal contact with general public and other co-workers

http://www.osha.gov/Publications/employers-protect-workers-flu-factsheet.html

Public Contact

• Schools• Grocery checkers,

bank tellers, etc.• Public offices such as

social services, DMV• Some public transit

and terminals

Workers Providing Health Care in Industry or Retail Environments

• On-site clinics/ employee health

• Retail health care• Pharmacies

Controls

OSHA’s suggested Control Measures for public contact

• Sneeze guards, drive through windows and other barriers

• Ventilation

• Social distancing

• Respiratory hygiene and hand hygiene

• Cleaning and disinfection of surfaces and hands

CDPH Guidance for State Facilities Employees

• Stay home if sick• Seek medical care if severe symptoms or if at

increased risk• If you need to go out when sick, wear a mask to

protect others• Wash hands frequently (or alcohol hand san)• Cover coughs and sneezes• Avoid touching eyes, nose mouth• Keep distance from people who are coughing• Avoid sharing personal items

http://www.cdph.ca.gov/HealthInfo/discond/Documents/CDPH-H1N1GuidanceforStateFacilities.pdf

CDPH Guidance for State Facilities supervisors and managers

• Review and update plans• Tell ees to stay home or go home if sick (7 days from onset)• E-mail, telework, teleconferences, web to minimize face-to-face • Maintain supply of tissues and hand hygiene products• Alcohol based hand san for staff, visitors, and residents • Avoid touching eyes, nose mouth• Clean common areas daily, increase cleaning of freq touched

surfaces• Post signs – cover cough• Increase outdoor air ventilation, by opening windows or

increase outdoor air supply rate if feasible (Myatt, TA et al. Detection of Airborne Rhinovirus and Its Relation to Outdoor Air Supply in Office Environments, AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 169 2004)

Personal Protection

We don’t Know:

• The specific route of transmission– Contact with eyes and mucous membranes– Inhalation and site of infection

• Whether the use of surgical masks or tissues by the source patient will provide added protection

Respirator Use

• Section 5144 regulates respirator use in the workplace

• Requires medical evaluation, training and fit-testing

• Employers who plan for employee respirator use in a pandemic should prepare in advance

Surgical Masks vs. Respirators

• Surgical masks are cheap and available• Surgical masks don’t require fit-testing• Some have recommended the use of

multiple surgical masks when N95’s weren’t available

• Filtration of surgical masks is highly variable

• Evidence does not support effectiveness of surgical masks against respiratory viruses

Respirators and Surgical Masks

Do N95’s need to be fit-tested?

1996 NIOSH laboratory study of 25 subjects with 21 models of N95s found

• Without fit-testing, the average protection factor for all subjects using a respirator was 3.

• By selecting out bad fits, using a fit-test, the average protection factor was 25

• Only four models passed a fit-test (factor of 100) for the majority of participants. Three did not pass the fit-test for any participant.

Laboratory Performance Evaluation of N95 Filtering Facepiece Respirators, 1996. MMWR Morb Mortal Wkly Rep. 1998 Dec 11;47(48):1045-9.

Robert B. Lawrence, Matthew G. Duling, Catherine A. Calvert and Christopher C. Coffey , 'Comparison of Performance of Three Different Types of Respiratory Protection Devices', JOEH 3:9, 465 - 474

Respirators vs. Surgical Masks

Respirator Supply Issues

• California has “stockpiled” about 40 million N95 filtering facepiece respirators for use in health care

• Hospitals– Some were able to shift stock– Some ran out in first week

• Medical suppliers reported shortages• Safety suppliers generally had stock, and

directed it to health care and local gov.

Respirator Use Questions

• FDA considers FF respirator in medical setting to be a single use medical device

• Can respirators be re-donned?• If so, under what conditions? • Is the respirator a hazard to patient?

– IOM report Reusability of Facemasks During an Influenza Pandemic: Facing the Flu available from www.nap.edu

• We have requested information from OSHA

Respirator fit testing

• Some respirators are similar design, but different materials, e.g.

• Current regulations require a fit test if N95 is substituted for surgical N95

9210 – N951870 Surgical N95

IIPP

• Every CA employer required to have an Injury and Illness Prevention Program (Section 3203)

• IIPP’s should address infectious diseases hazards of some occupations, e.g. health care, wildlife biologists.

• If a flu epidemic creates workplace hazards, OSHA and Cal/OSHA will issue additional guidance.

• The absence of a specific requirement to plan for pandemic flu should not prevent employers from assessing risks and developing plans

IIPP

Pandemic flu may impact existing IIPP’s

• Incorporate infection control measures

• Need to assess hazards due to changes in processes, supplies, products or use of space (e.g. alternate care sites)

• Would require additional training for employees

Recording

• Log 300 exempts recording of “common cold and flu”

• Are pandemic flu strains, or zoonotic flu strains included in this exemption?

• OSHA will make this determination – must be consistent in all states

Health Care Emergency• If the governor declares a state of emergency,

he may suspend some regulations– H1N1 JEOC established with CDPH and Cal EMA– No regulations suspended– Issues of stockpile access

• The need to protect employees at work will remain – whether it is through enforcement or other mechanisms

• Cal/OSHA will provide guidance as the situation unfolds

Resources

• OSHA -- Guidance on Preparing Workplaces for an Influenza Pandemic http://www.osha.gov/Publications/influenza_pandemic.html#affect_workplaces

• Cal/OSHA on the web: www.dir.ca.gov

• California Department of Public Health: http://www.cdph.ca.gov/HealthInfo/discond/Pages/SwineInfluenza.aspx