This afternoon, CDC and OSHA jointly announced release of CDC's Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. As expected, the guidance continues to recommend the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza. The recommendation is followed by the following statement: “This recommendation applies uniquely to the special circumstances of the current 2009 H1N1 pandemic during the fall and winter of 2009-2010 and CDC will continue to revisit its guidance as new information becomes available, within this season if necessary.”
CDC Director Thomas Frieden emphasized that the guidance specifically applies to the H1N1 2009 pandemic. He noted that respiratory protection is the last line of defense in a hierarchy of controls to prevent influenza transmission and he stressed that facilities should have a comprehensive plan that includes the other important mechanisms to protect health care workers.
Acknowledging the N95 shortage, Dr. Frieden pointed out that the new guidance gives significant consideration to supply issues. He also announced the release of a second document, “Regarding Respiratory Protection for Infection Control Measures for 2009 H1N1 Influenza among Healthcare Personnel” that provides, in question and answer format, information to assist healthcare facilities to optimize implementation of recommended respiratory protection practices in the context of shortages.
Jordon Barab, Assistant Secretary, OSHA, stated that upon worker request or complaint, OSHA will inspect health care institutions to make sure that they are following CDC guidance and that OSHA may issue citations under the Respiratory Protection Standard, as well as the General Duty Clause to keep workers free from hazards. OSHA will be issuing a detailed compliance document for inspectors within a couple of weeks. Regarding the N95 supply problem, Barab stated that employers who make a good faith effort to obtain N-95s will not be cited though they may receive a hazard alert letter that would enumerate other protection methods. A good faith effort, according to Barab, could be demonstrated by documents showing attempts to place orders or statements from suppliers.
The updated guidance expands on earlier guidance by emphasizing that successfully preventing transmission requires a comprehensive approach. Additional revisions from earlier guidance include: recommended time away from work for healthcare personnel, recommending facemasks when N95s are not available and recommending the establishment of procedures to manage visitors. The revised guidance also expands upon information on the hierarchy of controls.
Recommended Time Away from Work for Healthcare Personnel
According to the revised guidance, healthcare personnel who develop a fever and respiratory symptoms should be excluded from work for at least 24 hours after they no longer have a fever, without the use of fever-reducing medicines.
Facemasks
The revised guidance recommends facemasks for healthcare personnel who are not provided a respirator due to N95 supply shortages. Facemasks should be chosen over no protection. Routine chemoprohylaxis is not recommended for personnel wearing facemasks during the care of patients with suspected or confirmed 2009 H1N1 influenza.
Visitors
The updated guidance recommends establishing procedures for managing visitor access and movement within a facility to include:
- Limiting visitors for patients in isolation for influenza to persons who are necessary for the patient's emotional well-being and care.
- Scheduling and controlling visits to allow for:
- Screening for symptoms of acute respiratory illness before entering the facility.
- Instruction, before entering the patient’s room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy while in the patient's room.
- Visitors should be instructed to limit their movement within the facility
Hierarchy of Controls
The revised guidance recommends a hierarchy of controls approach to prevent exposure of healthcare personnel and patients and prevent influenza transmission within healthcare settings. The guidance ranks the preventive interventions in the following order: 1)elimination of exposures; 2) engineering controls; 3) administrative controls; and 4) personal protective equipment.
The CDC has also produced a question and answer supplement on respiratory protection for H1N1 infection control measures.