pandemic influenza preparedness and response guidance

Pandemic Influenza Preparednessand Response Guidance for

HealthcareWorkers and Healthcare Employers

OSHA 3328-05R 2009

Occupational Safety and Health Act of 1970“To assure safe and healthful working conditionsfor working men and women; by authorizingenforcement of the standards developed underthe Act; by assisting and encouraging the States intheir efforts to assure safe and healthful workingconditions; by providing for research, information,education, and training in the field of occupationalsafety and health.”

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Pandemic Influenza Preparednessand Response Guidance for

HealthcareWorkers and Healthcare Employers

Occupational Safety and Health AdministrationU.S. Department of Labor

OSHA 3328-05R2009

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Occupational Safety andHealth Administration

This document is not a standard or regulation, and it creates no new legal obligations. Likewise, itcannot and does not diminish any obligations established by Federal or state statute, rule or stan-dard. The document is advisory in nature, informational in content, and is intended to assistemployers in providing a safe and healthful workplace. The Occupational Safety and Health Actrequires employers to comply with hazard-specific safety and health standards. In addition, pursuantto Section 5(a)(1), the General Duty Clause of the Act, employers must provide their employees witha workplace free from recognized hazards likely to cause death or serious physical harm. Employerscan be cited for violating the General Duty Clause if there is a recognized hazard and they do nottake reasonable steps to prevent or abate the hazard.

ACRONYMS

CDC Centers for Disease Control and PreventionEPA U.S. Environmental Protection AgencyHEPA high-efficiency particulate airHHS U.S. Department of Health and Human ServicesJCAHO Joint Commission on Accreditation of Healthcare

OrganizationsLRN Laboratory Response NetworkNIOSH National Institute for Occupational Safety and HealthOSH Act Occupational Safety and Health Act of 1970OSHA Occupational Safety and Health AdministrationPAPR powered air-purifying respiratorPLHCP physician or another licensed healthcare professionalPPE personal protective equipmentRT-PCR reverse transcriptase polymerase chain reactionSARS severe acute respiratory syndromeSNS Strategic National StockpileSPN Sentinel Provider NetworkWHO World Health Organization

Contents

Introduction 5References 6

Influenza: Clinical BackgroundInformation 7Clinical Presentation of Influenza 8

Clinical Presentation of Seasonal Influenza 8Clinical Presentations of Prior Influenza

Pandemics 9Clinical Presentation of Highly Pathogenic

Avian Influenza in Humans 9Diagnosis 9

Clinical Diagnosis of Seasonal Influenza 9Laboratory Diagnosis of Seasonal Influenza 10Clinical Diagnosis of Pandemic Influenza 10Laboratory Diagnosis of Avian and

Pandemic Influenza 11Modes ofTransmission 11

Seasonal InfluenzaTransmission 11Pandemic InfluenzaTransmission 12

Treatment and Prevention 13Seasonal InfluenzaTreatment and Prevention 13Pandemic InfluenzaTreatment and Prevention 13

References 13

Infection Control 15Standard Precautions andTransmission-Based Precautions 15

Standard Precautions 15Contact Precautions 16Droplet Precautions 16Airborne Precautions 16

Compliance with Infection Control 17Hand Hygiene Compliance 17Respiratory Protection Compliance 17Organizational Factors that Affect

Adherence to Infection Control 18Facility Design, Engineering, andEnvironmental Controls 18

Facility Capacity 19Engineering Controls in Improvised Settings 19Airborne Infection Isolation Rooms 19Engineering Controls for Aerosol-Generating

Procedures for Patients with PandemicInfluenza 19

Cohorting 20Engineering Controls in Diagnostic and

Research Laboratories 20Autopsy Rooms for Cases of Pandemic

Influenza 20Administrative Controls 21

Respiratory Hygiene/Cough Etiquette 21Pandemic Influenza Specimen Collection

andTransport 21

PatientTransport within Healthcare Facilities 22Pre-Hospital Care and PatientTransport

Outside Healthcare Facilities 22Staff Education andTraining 22Care of the Deceased 24Patient Discharge 24Visitor Policies 24

Healthcare Worker Vaccination 24

Antiviral Medication for Prophylaxis andTreatment in Healthcare Workers 25

Occupational Medicine Services 25Worker Protection 25Recommendations for Occupational

Health Administrators 26Occupational Medical Surveillance and

Staffing Decisions 26Personal Protective Equipment 27

Gloves 27Gowns 27Goggles/Face Shields 27Respiratory Protection for Pandemic

Influenza 27PPE for Aerosol-Generating Procedures 31Order for Putting on and Removing PPE 31

Work Practices 32Hand Hygiene 32Other Hygienic Measures 32Facility Hygiene—Practices and Polices 32Laboratory Practices 34

References 34

Pandemic Influenza Preparedness 36Healthcare Facility Responsibilities DuringPandemic Alert Periods 36

Healthcare Facility Responsibilities DuringPandemic Alert Periods (HSC Stages 0, 1) 36

Healthcare Facility Responsibilities Duringthe Pandemic (HSC Stages 2-5) 37

Healthcare Facility Recovery and Preparationfor Subsequent Pandemic Waves(HSC Stage 6) 37

Incorporating Pandemic Plans intoDisaster Plans 37

Pandemic Planning for Support ofHealthcare Worker Staff 37

Define Essential Staff and Hospital Services 38Human Resources 39InformationTechnology 39Public Health Communication 39Surveillance and Protocols 40Psychological Support 41Occupational Health Services 42Developing and Providing Employee

Screening for Influenza-Like Illness 42

P A N D E M I C I N F L U E N Z A P R E P A R E D N E S S A N D R E S P O N S E G U I D A N C E F O RH E A L T H C A R E W O R K E R S A N D H E A L T H C A R E E M P L O Y E R S

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Developing and Providing Immunization andTreatment Strategies 42

Continuing Baseline Occupational HealthServices 43

Training 43Security 43

Stockpiles of Essential Resources 44Pandemic Influenza Vaccine 44Antiviral Medication 45Personal Protective Equipment 46Outpatient Services and Clinics 46Alternate Care Sites 47

References 47

OSHA Standards ofSpecial Importance 50Respiratory Protection Standard -

29 CFR 1910.134 50Personal Protective Equipment Standard -

29 CFR 1910.132 50Bloodborne Pathogens Standard -

29 CFR 1910.1030 50General Duty Clause 51References 51

Appendix APandemic InfluenzaInternet Resources 52

Appendix BInfection Control CommunicationTools for Healthcare Workers 54Appendix B-1Factors Influencing Adherence toHand Hygiene Practices 55Appendix B-2Elements of Healthcare Worker Educationaland Motivational Programs 56Appendix B-3Strategies for Successful Promotion of HandHygiene in Hospitals 57Appendix B-4Pandemic Influenza Precautions for VeteransAdministration Healthcare Facility Staff 58Appendix B-5Public Health Measures Against PandemicInfluenza for Individuals, Healthcare Providers,and Organizations 60

Appendix CImplementation and Planning forRespiratory Protection Programsin Healthcare Settings 62Appendix C-1Respiratory Protection Programs 62

Appendix C-2Readiness Plan for Epidemic RespiratoryInfection: A Guideline for Operations for Useby the Dartmouth-Hitchcock Medical Center –Lebanon Campus and the Dartmouth CollegeHealth Service 67

Appendix DSelf-Triage and Home Care Resourcesfor Healthcare Workers and Patients 82Appendix D-1Sample Self-Triage Algorithm for Personswith Influenza Symptoms 82Appendix D-2Home Care Guide for Influenza 83

Appendix EReferences for Diagnosis andTreatment of Staff During anInfluenza Pandemic 85Appendix E-1Influenza DiagnosticTable 85

Appendix FPandemic Planning Checklistsand Example Plans 87Appendix F-1Sample Emergency Management ProgramStandard Operating Procedure (SOP) 88

Appendix GRisk Communication Resources 94Appendix G-1Risk and Crisis Communication: 77 QuestionsCommonly Asked by Journalists Duringa Crisis 95

Appendix HSample Supply Checklistsfor Pandemic Planning 96Appendix H-1Examples of Consumable and DurableSupply Needs 96Appendix H-2Suggested Inventory of Durable and ConsumableSupplies for Veterans Administration HealthcareFacilities During a Pandemic Influenza 96

OSHA Assistance 97

OSHA Regional Offices 99

IntroductionA pandemic is a global disease outbreak. A flu pan-demic occurs when a new influenza virus emergesfor which people have little or no immunity, and forwhich there is no vaccine. The disease spreads eas-ily person-to-person, causes serious illness, andcan sweep across the country and around theworld in a very short time.

It is difficult to predict when the next influenzapandemic will occur or how severe it will be.Wherever and whenever a pandemic starts, every-one around the world is at risk. Countries might,through measures such as border closures andtravel restrictions, delay arrival of the virus, butthey cannot stop it.

An especially severe influenza pandemic couldlead to high levels of illness, death, social disrup-tion, and economic loss. Everyday life would bedisrupted because so many people in so manyplaces become seriously ill at the same time.Impacts can range from school and business clos-ings to the interruption of basic services such aspublic transportation and food delivery.

An influenza pandemic is projected to have aglobal impact on morbidity and mortality, thusrequiring a sustained, large-scale response fromthe healthcare community. The 1918 influenza pan-demic was responsible for over 500,000 deaths inthe United States, while the 1957 and 1968 pan-demic influenza viruses were responsible for 70,000and 34,000 deaths, respectively.1 More recently, onemodeling study estimated that an influenza pan-demic affecting 15 to 35 percent of the UnitedStates population could cause 89,000 to 207,000deaths, 314,000 to 734,000 hospitalizations, 18 to 42million outpatient visits, and 20 to 47 million addi-tional illnesses.2 In contrast, from 1990 to 1999, sea-sonal influenza caused approximately 36,000deaths per year in the United States.3

A substantial percentage of the world’s popula-tion will require some form of medical care.Healthcare facilities can be overwhelmed, creatinga shortage of hospital staff, beds, ventilators andother supplies. Surge capacity at non-traditionalsites such as schools may need to be created tocope with the demand.

It is expected that such an event will quicklyoverwhelm the healthcare system locally, regional-ly, and nationally.4 An increased number of sickindividuals will seek healthcare services. In addi-tion, the number of healthcare workers available torespond to these increased demands will bereduced by illness rates similar to pandemic

influenza attack rates affecting the rest of the popu-lation. Finally, healthcare workers and healthcareresources will also be expected to continue to meetnon-pandemic associated healthcare needs.

In order to mitigate the effects of an influenzapandemic on the healthcare community, it is impor-tant to identify healthcare providers and recognizethe diversity of practice settings.

• The delivery of healthcare services requires abroad range of employees, such as firstresponders, nurses, physicians, pharmacists,technicians and aides, building maintenance,security and administrative personnel, socialworkers, laboratory employees, food service,housekeeping, and mortuary personnel.Moreover, these employees can be found in avariety of workplace settings, including hospi-tals, chronic care facilities, outpatient clinics(e.g., medical and dental offices, schools, phys-ical and rehabilitation therapy centers, healthdepartments, occupational health clinics, andprisons), free-standing ambulatory care andsurgical facilities, and emergency response set-tings.

• The diversity among healthcare workers andtheir workplaces makes preparation andresponse to a pandemic influenza especiallychallenging. For example, not all employees inthe same healthcare facility will have the samerisk of acquiring influenza, not all individualswith the same job title will have the same riskof infection, and not all healthcare facilities willbe at equal risk although all will be similarlysusceptible. During an influenza pandemic,healthcare workers may be required to provideservices in newly established healthcare facili-ties to accommodate patient overflow from tra-ditional healthcare settings (e.g., conventioncenters, schools, and sports arenas).Consequently, the cornerstone of pandemicinfluenza preparedness and response is anassessment of risk and the development ofeffective policies and procedures tailored to theunique aspects of various healthcare settings.

Collaboration with state and federal partners isvital to ensure that healthcare workers are ade-quately protected during an influenza pandemic.The goal of this document is to help healthcareworkers and employers prepare for and respond toan influenza pandemic.

The guidance document is organized into fourmajor sections:

• Clinical background information on influenza


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Intro

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• Infection control• Pandemic influenza preparedness• OSHA standards of special importance

Given the technical nature and breadth of infor-mation available in the document, each section hasbeen subdivided (see Table of Contents) in order toallow readers to quickly focus on areas of interest.

The document also contains appendices whichprovide pandemic planners with samples of infec-tion control plans, examples of practical pandemicplanning tools and additional technical information.Topic areas include Internet resources, communica-tion tools, sample infection control programs, self-triage and home care resources, diagnosis andtreatment of staff during a pandemic, planning andsupply checklists and risk communication. Thiseducational material has been provided for infor-mational purposes only and should be used in con-junction with the entire document in order to ensurethat healthcare workers are adequately protectedduring a pandemic. OSHA does not recommendone option over the many effective alternatives thatexist.

OSHA has prepared additional, general informa-tion to assist workplaces in their preparation for aninfluenza pandemic entitled, Guidance on PreparingWorkplaces for an Influenza Pandemic which isavailable at www.osha.gov.

References1 U.S. Department of Health and Human Services(HHS). Pandemicflu.gov, General Information. Lastaccessed June 7, 2006: http://www.pandemicflu.gov/general/.2 Meltzer M.I., N.J. Cox, K. Fukuda. 1999. The eco-nomic impact of pandemic influenza in the UnitedStates: priorities for intervention. Emerg Infect Dis5:659-71.3 Thompson W.W., D.K. Shay, E. Weintraub, et al.2003. Mortality associated with influenza and respi-ratory syncytial virus in the United States. JAMA289:179-86.4 Waldhorn R., E. Toner. 2005. Challenges to hospi-tal medical preparedness and response in a flu pan-demic. Center for Biosecurity, University ofPittsburgh Medical Center. October 12, 2005. Lastaccessed June 7, 2006: http://www.upmc-biosecuri-ty.org/avianflu/facts-hospitalprep.html

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Influenza: ClinicalBackground InformationHistorically, influenza has caused outbreaks of res-piratory illness for centuries, including three pan-demics (worldwide outbreaks of disease) in the20th century.1 There are three types of influenzaviruses: types A, B, and C. Only type A influenzaviruses cause pandemics. Seasonal influenza out-breaks can be caused by either type A or type Binfluenza viruses. Influenza type C viruses causemild illness in humans but do not cause epidemicsor pandemics. This guidance is aimed at protectinghealthcare workers in the event of an influenza pan-demic; therefore, the focus will be on the character-istics of type A influenza viruses.

Of the three types of influenza viruses, only typeA is divided into subtypes. Subtype designationsare based on the presence of two viral surfaceproteins (antigens): hemagglutinin (H) and neur-aminidase (N). To date, 16 different hemagglutininand 9 different neuraminidase surface proteinshave 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 the20th 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 canoccur in humans. It is important to have a basicunderstanding of the terms seasonal, avian andpandemic influenza in order to appreciate the guid-ance in this document.

• Seasonal influenza or “flu” refers to periodicoutbreaks of acute onset viral respiratory infec-tion caused by circulating strains of humaninfluenza A and B viruses. Seasonal “flu” is thekind of influenza with which healthcare work-ers and the public are most familiar. In temper-ate regions of the world, seasonal influenzagenerally occurs most frequently during thewinter months when the humidity and outdoortemperatures are low (generally from Decemberuntil April in northern temperate regions).Between 5–20 percent of the population maybe infected annually. Most people have someimmunity to the currently circulating strains ofinfluenza virus and, as a result, the severityand impact of seasonal influenza is substantial-ly less than during pandemics. Each year, atrivalent influenza vaccine is prepared in

advance of the anticipated seasonal outbreakand it includes those strains (two type A andone type B) that are expected to be the mostlikely to circulate in the upcoming “flu” season.Influenza vaccine is currently targeted towardthose at greatest risk of influenza-related com-plications and their contacts, such as health-care workers.

• Avian influenza, also known as the bird flu, iscaused by type A influenza viruses that infectwild birds and domestic poultry. Some formsof the avian influenza are worse than others.Avian influenza viruses are generally dividedinto two groups: low pathogenic avian influen-za and highly pathogenic avian influenza. Lowpathogenic avian influenza naturally occurs inwild birds and can spread to domestic birds. Inmost cases it causes no signs of infection oronly minor symptoms in birds. In general,these low pathogenic strains of the virus poselittle threat to human health. Low pathogenicavian influenza virus H5 and H7 strains havethe potential to mutate into highly pathogenicavian influenza and are, therefore, closelymonitored. Highly pathogenic avian influenzaspreads rapidly and has a high death rate inbirds. Highly pathogenic avian influenza of theH5N1 strain is rapidly spreading in birds insome parts of the world.

Highly pathogenic H5N1 is one of the few avianinfluenza viruses to have crossed the species barri-er to infect humans, and it is the most deadly ofthose that have crossed the barrier. Most cases ofhighly pathogenic H5N1 infection in humans haveresulted from contact with infected poultry or sur-faces contaminated with secretion/excretions frominfected birds.

As of November 2006, the spread of highlypathogenic H5N1 avian influenza virus from personto person has been limited to rare, sporadic cases.Nonetheless, because all influenza viruses have theability to change, scientists are concerned thathighly pathogenic H5N1 avian influenza virus oneday could be able to sustain human-to-humantransmission. Because these viruses do not com-monly infect humans, there is little or no immuneprotection against them in the human population.If the highly pathogenic H5N1 avian influenza viruswere to gain the capacity to sustain transmissionfrom person to person, a pandemic could begin.

• Pandemic influenza refers to a global diseaseoutbreak. A flu pandemic occurs when a newinfluenza type A virus emerges for which peo-


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ple have little or no immunity, and for whichthere is no vaccine. The disease spreads easilyperson-to-person, causes serious illness, andcan sweep across the country and around theworld in a very short time. Such a virus is likelyto have origins from avian viruses or possiblyfrom other animal sources (e.g., pigs). Manyscientists believe that since no pandemic hasoccurred since 1968, it is only a matter of timebefore another pandemic occurs. A pandemicmay occur in waves of outbreaks with eachwave in a community lasting 8 to 12 weeks.One-to-three waves may occur.

Rapid detection of unusual influenza outbreaks,isolation of possible pandemic viruses and the imme-diate notification of national and international healthauthorities is critical for mounting a timely and effec-tive response to a potential pandemic. The WorldHealth Organization (WHO) maintains a global sur-veillance system of circulating influenza strains and aGlobal Influenza Preparedness Plan.3 The WHO Plandescribes six phases of increasing public health riskassociated with the emergence of a new influenzavirus subtype that may pose a pandemic threat. TheWHO bases alerts on these six different phases.

The first two phases of the WHO Pandemic AlertSystem comprise the “Inter-pandemic Period” inwhich there is a novel influenza A virus in animals,but no human cases have been observed. Phase 2indicates that an animal influenza subtype thatposes a risk to humans has been detected. The nextthree phases (Phases 3–5) compose the “PandemicAlert Period” in which a novel influenza virus caus-es human infection with a new subtype, but doesnot exhibit efficient and sustained human-to-humantransmission. Once a new influenza A virus devel-ops the capacity for efficient and sustained human-to-human transmission in the general population(Phase 6), the WHO declares that an influenza pan-demic is in progress (this is known as the“Pandemic Period”).

For additional information visit WHO’s Epidemicand Pandemic Alert and Response website athttp://www.who.int/csr/disease/avian_influenza/phase/en/index.html. Federal government responsestages to these WHO phases are described in theNational Strategy for Pandemic Influenza:Implementation Plan which can be found athttp:// www.whitehouse.gov/ homeland/pandemicinfluenza-implementation.html.

Clinical Presentation of Influenza

It may be useful for healthcare providers to beaware of the clinical presentation of seasonal

influenza, prior influenza pandemics, and highlypathogenic avian influenza in humans to assistthem when evaluating patients who present withinfluenza-like illness.

The clinical picture of influenza infections canvary from no symptoms at all in seasonal influenzato fulminant (fully symptomatic) disease in pan-demic strains that result in severe illness and death,even among previously healthy adults and children.4

Fever and respiratory symptoms are characteristicof all forms of influenza. The Centers for DiseaseControl and Prevention’s (CDC’s) Sentinel ProviderNetwork (SPN) monitors influenza timing andseverity. The SPN5 is comprised of approximately2,300 primary care providers that provide weeklyreports on outpatient “influenza-like illnesses” tostate health departments and to the CDC. The SPNuses “fever >100° F or 37.8° C and sore throatand/or cough in the absence of a known causeother than influenza” as its definition of influenza-like illness.

Clinical Presentation of Seasonal InfluenzaSeasonal influenza typically has an abrupt onset,with symptoms of fever, chills, fatigue, muscleaches, headache, dry cough, upper respiratory con-gestion, and sore throat.6 The time from exposureto disease onset is usually 1 to 4 days, with anaverage of 2 days. Most patients recover within 3 to7 days.7 In adults, fevers usually last for 2 to 3 days,but may last longer in children. Cough and weak-ness can persist for up to 2 weeks. Except for fever,the physical examination has few specific findings.Typically there is weakness and mild inflammationof the upper respiratory tract. Routine outpatientlaboratory findings are also non-specific. Availablelaboratory tests that are specific for influenza aredescribed in the Diagnosis section on page 9 of thisdocument.

Adults are possibly infectious from about 1 daybefore until about 5 days after the onset of clinicalillness. Children and the immunocompromised(e.g., people with HIV infection, organ transplanta-tion or receiving chronic steroids) have a muchlonger period of infectivity. Children can be infec-tious for 10 or more days, and young children canshed the virus for several days before the onset ofillness. Severely immunocompromised persons canshed the virus for weeks or months.7

Seasonal influenza is responsible for approxi-mately 36,000 deaths and 226,000 hospitalizationsannually in the United States.8 The risk of death ishighest among the elderly, the very young, andpatients with cardiopulmonary and other chronicconditions.7

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Clinical Presentations of Prior InfluenzaPandemicsThe 1918 influenza pandemic, caused by subtypeH1N1 viruses, had signs and symptoms of fargreater severity than seasonal influenza. It resultedin death for an estimated 500,000 U.S. citizens andas many as 40 million people worldwide. The 1918pandemic disproportionately affected young,healthy adults, between the ages of 15 and 35. Asignificant proportion of patients developed fulmi-nant disease, accompanied by a striking perioralcyanosis, leading to death within a few days.Postmortem examinations in these patients fre-quently revealed denuding tracheobronchitis, pul-monary hemorrhage, or pulmonary edema. Otherssurvived the initial illness, only to die of a second-ary bacterial pneumonia.6

The 1957 (caused by subtype H2N2 viruses) and1968 (caused by subtype H3N2 viruses) influenzapandemics killed an estimated 70,000 and 34,000U.S. citizens, respectively.8 The clinical features ofthe pandemics of 1957 and 1968 were also typicalof influenza-like illness, including fever, chills,headache, sore throat, malaise, cough, and coryza,but were milder compared to the 1918–19 pandem-ic.6 The 1957 influenza pandemic was notable forsevere complications, such as primary viral pneu-monia, particularly in pregnant women. As in thepandemic of 1918, some people survived the initialviral infection, only to later die of a secondary bac-terial pneumonia.

Clinical Presentation of Highly PathogenicAvian Influenza in HumansThe highly pathogenic H5N1 avian influenza virusthat caused outbreaks in Hong Kong, Thailand,Vietnam, and Cambodia, like the 1918 pandemicvirus, primarily resulted in disease in children andyoung adults.9 Hospitalized patients initially devel-oped typical seasonal influenza symptoms such ashigh fever and cough, but unlike seasonal influenza,there were lower respiratory tract rather than upperrespiratory tract symptoms. Because of the involve-ment of the lower respiratory tract, patients typical-ly had shortness of breath and almost all patientshad developed viral pneumonia at the time of hos-pitalization. Also unlike typical seasonal influenza,diarrhea, abdominal pain, and vomiting were fre-quently reported. Common laboratory findingswere lymphopenia, thrombocytopenia and elevatedaminotransferase levels.

As of November 13, 2006, highly pathogenicH5N1 viruses had not been detected in animals orhumans in the United States. For up-to-date infor-mation regarding the number of human cases of

avian influenza and deaths worldwide, visit theWHO 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 employeesand those helping to contain the outbreak in theNetherlands in 2003.10 The clinical course of thisinfluenza virus was unusual in that conjunctivitiswas a common finding and fewer affected personshad respiratory symptoms, although the one fatali-ty among the 89 human cases was associated withrespiratory disease. No further outbreaks werereported through April 24, 2006 (http://www.cdc.gov/flu/avian/gen-info/avian-flu-humans.htm).

Diagnosis

Accurate and timely influenza diagnosis requiresknowledge of the likely clinical presentations ofseasonal influenza and of any circulating strains ofnovel viral subtypes, an awareness of the risks forexposure, and knowledge of the capabilities andlimitations of laboratory diagnostic tests.

The more quickly a new pandemic virus can beidentified, the sooner actions can be taken to isolatethe initial cases and initiate other public healthmeasures to prevent spread through the communi-ty and the sooner infection control measures canbe implemented to protect the community’s health-care workers.

Clinical Diagnosis of Seasonal InfluenzaUncomplicated seasonal influenza presents as asudden onset of fever and respiratory illness withmuscle aches, headaches, nonproductive cough,sore throat, and runny nose. Children can also haveear infections and/or gastrointestinal symptoms.7

The diagnosis of the influenzas will be primarilythrough recognizing symptom complexes such asthose used in surveillance. The SPN definition forinfluenza-like illness is used for seasonal influenzasurveillance.5 However, this definition is not specificand may share features with other respiratory ill-nesses present in the community.

The likelihood of a clinical sign or symptom toaccurately detect influenza infection in a group ofpatients is called sensitivity. Conversely, the likeli-hood of a clinical sign or symptom to excludeinfluenza infection in a group of patients who donot have influenza is called specificity. Both thesensitivity and specificity of clinical signs andsymptoms of influenza infection vary with multiplefactors, including patient age, vaccination status,hospitalization status, degree of co-circulation ofother infectious agents that cause respiratory


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symptoms in the community, and the percentage ofthe population infected with influenza (prevalence).The clinical signs and symptoms of influenza havebeen studied using viral cultures as the criteria fordefinitive influenza diagnosis in groups of mostlyyoung adults when influenza was circulating in theircommunity. It has been reported that the use of theinfluenza-like case definition is 63 to 78% accuratein identifying culture-confirmed cases of influenza(a sensitivity of 63 to 78%) and 55 to 71% accuratein excluding influenza (specificity of 55 to 71%).7

The sensitivity and specificity will vary based on thepercentage of all respiratory illnesses that are dueto influenza. Other studies have addressed influenzasigns and symptoms in different groups.11, 12

There is considerable overlap in the clinical pres-entation of seasonal influenza and other viral andbacterial respiratory infections. Influenza surveil-lance case definitions and laboratory testing canassist in differentiating among these infections.However, clinicians must always maintain a level ofawareness that co-infections with bacterial respira-tory infections or non-influenza viruses can occurwith seasonal influenza. Clinical judgment regard-ing diagnosis and treatment is needed in conjunc-tion with laboratory testing in order to differentiatebetween potential infectious organisms.

Laboratory Diagnosis of Seasonal InfluenzaDuring Inter-pandemic and Pandemic Alert Periods,use of laboratory diagnostic tests for influenza sup-ports seasonal influenza surveillance and provideslaboratory detection of novel influenza subtypes.There are multiple laboratory techniques for identi-fying influenza viruses, including the rapid antigentest, the reverse transcriptase polymerase chainreaction (RT-PCR) assays, virus isolation, andimmunofluorescence antibody assays.13

When respiratory secretions are used for sea-sonal influenza diagnosis, nasopharyngeal samplesare more likely to yield a positive result than arepharyngeal swab samples.14 Commercial rapid test-ing can detect influenza virus in less than 30 min-utes. However, some of these tests are not verysensitive9 (false negative results are common) andnot all of these tests are able to distinguish betweeninfluenza A and B viruses (see Safety Tips forLaboratorians: Cautions in Using Rapid Tests forInfluenza A Viruses at http://www.fda.gov/cdrh/oivd/tips/rapidflu.html). When influenza is suspected dur-ing an outbreak of respiratory illness, both rapidtesting and viral cultures should be done. Althoughviral cultures require five days or more to perform,they can provide specific information on the strain

and subtype of the influenza virus tested, and pro-vide information on the sensitivity to antiviral med-ication as well.14 The HHS/CDC Influenza (Flu)Laboratory Diagnostic Procedures for Influenzawebsite (http://www.cdc.gov/flu/professionals/labdiagnosis.htm) maintains a table of the availablediagnostic tests for the influenza virus.14

Clinical Diagnosis of Pandemic InfluenzaPatients with pandemic influenza will likely haveclinical signs and symptoms similar to seasonalinfluenza, although the clinical presentation andcourse of illness may be severe in a higher percent-age of the cases of pandemic influenza. In general,if the next pandemic is comparable to the 1918Type A H1N1 virus, the pandemic influenza is likelyto be far more severe than seasonal influenza, andmight disproportionately affect a younger popula-tion.

An important factor to look for when evaluatingpatients for the presence of pandemic influenzaduring all phases of a WHO Pandemic Alert Period,when human infection with a new subtype is detect-ed, is a possible source of exposure. For instance,the current sources of exposure to highly pathogen-ic H5N1, the avian influenza virus of most concern,would likely involve international travel or occupa-tional exposure to infected poultry or wild birds.Emergency room physicians and other healthcarepersonnel interviewing patients with influenza-likeillness should ask about recent travel history.

A patient who has a history of travel to a coun-try affected by a novel influenza virus and who hasthe onset of influenza-like illness within the knownincubation period for that virus should be suspect-ed to be infected with the novel influenza virus.Seasonal influenza incubation is usually 1 to 4days, but novel influenza viruses may have longerincubation periods, possibly up to 10 days.6 A fre-quently updated report of countries that have hadhuman infections with highly pathogenic H5N1avian influenza viruses is available at the WHOWeb website at http://www.who.int/csr/disease/avianinfluenza/en/.

Individuals who handle or process animals witha novel virus, laboratory personnel who analyzespecimens containing a novel virus and healthcareworkers who care for patients infected with a novelvirus are at risk for contracting that viral infection. Ifthe virus of concern has not yet been shown to becapable of sustained human-to-human transmis-sion, occupational risk would be higher for employ-ees with exposure to animal or animal products.6

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Laboratory Diagnosis of Avian andPandemic InfluenzaCurrently, the highly pathogenic H5N1 avianinfluenza virus is considered to have the greatestpotential for mutation to a pandemic virus givenhow widespread the virus is and because it hasalready caused illness and death in people. Thisvirus has spread rapidly in bird populationsthroughout Asia, Europe, and Africa. Recently,HHS/CDC developed a 4-hour RT-PCR assay for thedetection of the gene coding for the H5 surface pro-tein of the Asian lineage of the highly pathogenicH5N1 avian influenza virus.15 These RT-PCR reagentshave been distributed to approximately 140 desig-nated laboratories of the Laboratory ResponseNetwork (LRN) which has laboratories located in all50 states.15 The RT-PCR testing should be donewhen a patient has severe respiratory illness andclinical or epidemiological risk. Clinicians shouldcontact their local or state health department assoon as possible to report any suspected humancase of influenza H5N1 in the United States.Positive tests for influenza A H5N1 in the UnitedStates should be confirmed by HHS/CDC, which hasbeen designated as a WHO H5 Reference laborato-ry. An HHS/CDC guidance document UpdatedInterim Guidance for LaboratoryTesting of Personswith Suspected Infection with Avian Influenza A(H5N1)Virus in the United States is distributed viathe Health Alert Network (HAN) at http://www2a.cdc.gov/han/ArchiveSys/ViewMsgV.asp?AlertNum=00246. Tests for other avian viruses with pandemicpotential are also being developed.

Modes ofTransmission

Information on the mode of seasonal influenzatransmission is based on previous influenza out-breaks. However, the transmission characteristics ofa pandemic influenza virus will not be known untilafter the pandemic begins. This section covers thetransmission patterns of seasonal influenza andpast and potential pandemic influenza outbreaks.

Seasonal InfluenzaTransmissionThe usual method of seasonal influenza transmis-sion is assumed to be through coughs and sneezesof infected persons within close proximity. A sus-ceptible person may develop symptoms within 1 to4 days after exposure to an infected patient who isshedding the influenza virus. The newly infectedperson is then infectious for about 6 days, usuallybeginning 1 day prior to the onset of symptoms.This varies with age and disease, as discussed pre-viously.


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The relative importance of the various routes oftransmission is not known, although it is now com-monly accepted that the spread of seasonal influen-za requires close proximity—via exposure to largedroplets (droplet transmission), direct contact(contact transmission), or near range exposure toaerosols.16 The term “near range” is used to differ-entiate influenza airborne transmission from thelong-range airborne transmission seen in diseasessuch as tuberculosis, where disease spread canoccur over long distances and prolonged periodsof time.

DropletTransmissionEpidemiologic patterns suggest that droplet trans-mission is a major route of influenza spread.Susceptible individuals are subject to infection bylarge particle droplets from infected patients.Droplets are produced by coughing, sneezing, ortalking, or by therapeutic manipulations such assuctioning or bronchoscopy. Infected droplets mayenter the susceptible individual through the con-junctiva of the eye or the mucus membranes of themouth or nose. Droplets travel only about 3 feetand do not remain in the air, so special ventilationprocedures and advanced respiratory protection isnot required to prevent this type of transmission.16

AirborneTransmissionAirborne transmission, as occurs in tuberculosis, isspread through small infectious particles such asdroplet nuclei.17 Unlike the larger droplets, thesevery small airborne droplet nuclei can be readilydisseminated by air currents to susceptible individ-uals. They can travel significant distances and canpenetrate deep into the lung to the alveoli wherethey can establish an infection. The presence of sig-nificant airborne transmission would indicate theneed for ventilation procedures and respiratory pro-tection greater than that afforded by a surgicalmask, e.g., a NIOSH-certified N95 or higher respira-tor.

No study has definitively established airbornetransmission as a major route of influenza trans-mission, but multiple studies suggest that someairborne influenza transmission may occur.Experiments in mice have demonstrated that airexchange can decrease influenza virus transmis-sion, and have demonstrated infectious particlesthat are smaller than ten microns.18 A ferret studydemonstrated that influenza virus transmission canoccur through a vent with right angles. A humanvolunteer study demonstrated that, when a smalldroplet aerosol is used, influenza transmission can

occur with lower virus concentrations.19 Anotherhuman observational study documented the spreadof influenza to 72 percent of the passengers andcrew on an airplane with a ventilation system thatwas not functioning for 3 hours.20 While these stud-ies suggest that airborne influenza transmissionoccurs under certain conditions, the proportion ofinfluenza illness resulting from this route of trans-mission is unknown.

ContactTransmissionContact transmission can be direct or indirect.Direct contact transmission occurs by touching skinto skin, usually during direct patient care activitiessuch as turning or bathing patients, or by shakinghands. Indirect transmission occurs when infectedmaterial from the patient is deposited in the envi-ronment and is taken up by a susceptible individual.16

There is limited data on the survivability ofinfluenza A and B viruses outside of the humanhost. One study,21 conducted by Bean et al., sug-gests that that if a heavily infected person contami-nated a stainless steel surface, there might beenough viable viral particles remaining after 2-8hours to allow contact transmission to a susceptibleperson. It should be noted that this study was con-ducted at a relative humidity of 35 to 40 percent, alevel that favors the survival of influenza viruses.Other studies have clearly demonstrated thathumidity plays a significant role in influenza viralsurvival with survival times being longer at lowerhumidity.

Further research is needed to more fully appre-ciate the role of contact transmission for variousstrains of influenza and the effect of varying envi-ronmental conditions. Although it is assumed thatinfluenza spreads by contact transmission, the pro-portion of spread that occurs through this mecha-nism is unknown.16

Pandemic InfluenzaTransmissionThis section discusses observational studies onhuman-to-human transmission during previousinfluenza pandemics and observations about impli-cations for transmission of current avian influenzavirus infections that are of concern for possiblefuture influenza pandemics.

Transmission, Past PandemicsOne influenza transmission study conducted duringthe 1957 pandemic indicated the importance of per-son-to-person spread while another suggested theapparent importance of airborne transmission. Thefirst study, an epidemiological study demonstrated

influenza transmission from a newly hospitalized,infected patient who had no isolation precautionsto three healthcare workers and one adjacentpatient. Ultimately, 30 of the 62 exposed patientsand ward staff became ill.22 Although the authorsdid not address the likely mode of transmission, alater analysis of the data was interpreted as notconsistent with a single source pattern as would beseen in airborne transmission.17 The second study,an observational influenza transmission study dur-ing the 1957 pandemic conducted at a VeteransAdministration Hospital suggested airborne trans-mission. The study compared the influenza illnessrates in tuberculosis patients in wards with andwithout ultraviolet ceiling lights and found rates of2 percent and 19 percent, respectively. The authorsof this study suggest this finding implies that trans-mission of influenza was significantly blocked byradiant (UV) disinfection of droplet nuclei.23

Transmission, Possible Future PandemicsThe influenza viruses that are currently of greatestconcern for possible future pandemics are the high-ly pathogenic avian influenza viruses, most notablystrains of H5N1 and H7N7, which have caused out-breaks among humans.

A summary of the clinical features of hospital-ized patients with highly pathogenic H5N1 avianinfluenza described a clinical course that differedfrom seasonal influenzas. The highly pathogenicH5N1 avian influenza had an initial presentationwith lower respiratory tract symptoms and viralpneumonia (seasonal influenzas present more oftenwith upper respiratory symptoms), a higher ribonu-cleic acid detection in pharyngeal samples (season-al influenzas have higher viral detection in nasalsamples), and more frequent diarrhea, abdominalpain, and vomiting. The detection of infectiousvirus and ribonucleic acid in the blood, cere-brospinal fluid (CSF) and feces of one patient, achild,9 raises concern that transmission of this virusmay be possible by contact with blood, CSF andfeces in addition to respiratory secretions, but thisremains unknown.

An outbreak of highly pathogenic H7N7 avianinfluenza virus occurred in poultry farm employeesin the Netherlands in 2003.10 This influenza’s clinicalcourse was unique in that it was mainly associatedwith conjunctivitis. Seasonal influenza transmissionis considered to take place primarily through therespiratory tract, but the conjunctivitis componentof highly pathogenic H7N7 avian influenza suggeststhat its transmission may also occur via the mucousmembranes of the eye.

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Treatment and Prevention

Treatment and prevention of influenza involvesmultiple infection control measures, including vac-cination, antiviral medications, and management ofinfluenza complications. This section concentrateson immunization and antiviral medications.

Seasonal InfluenzaTreatment and PreventionMedications available for influenza A treatment andprophylaxis include the M2 ion channel inhibitors(also known as adamantanes) amantadine andrimantadine and the neuraminidase inhibitorszanamivir and oseltamivir. Presently, only the neu-raminidase inhibitors are available for treatmentand prophylaxis of both influenza A and B. CurrentHHS/CDC drug recommendations, announced dur-ing the 2005-2006 influenza season (see http://www.cdc.gov/flu/han011406.htm), advise againstthe use of adamantanes for seasonal influenza dueto resistance. Therefore, the neuraminidaseinhibitors oseltamivir and zanamivir are the onlydrugs currently recommended for treatment andprophylaxis of influenza. Neuraminidase inhibitorsare prescription drugs and they are most effectivefor treatment when use begins within two days ofsymptom onset. Clinicians should adhere toHHS/CDC recommendations regarding the use ofantivirals.24

Antiviral medications can be used to preventinfluenza, but the primary strategy for preventinginfluenza infections is vaccination. Vaccines areavailable in two forms: 1) as an intranasal liveattenuated vaccine and 2) as an injectable, inacti-vated trivalent vaccine. Indications and contraindi-cations differ among the preparations.25 Annualvaccination has been shown to reduce the inci-dence of influenza infections in healthcare work-ers.25, 26, 27 Infection control measures are anothermeans to prevent infection, but their benefit is lesswell established.

Pandemic InfluenzaTreatment and PreventionThe appropriate use of antiviral drugs during apandemic could reduce mortality and morbidity. Atthe time of this writing, HHS recommendations fortreatment of novel viruses are to use the neur-aminidase inhibitors zanamivir and oseltamivirbecause of influenza resistance to amantadine andrimantadine.24

Although the magnitude of drug effect againstinfections with novel strains cannot be predictedprecisely, early use is expected to be important fordrug effectiveness. The availability of adequateantiviral supplies during a pandemic is far from cer-

tain, and, therefore, the HHS Pandemic InfluenzaPlan provides antiviral drug use priority recommen-dations. Healthcare workers are included in the pri-ority group recommendations.28

A vaccine against a specific pandemic influenzastrain will likely not be available until after the pan-demic begins. But vaccinations against seasonalinfluenza during the WHO’s Interpandemic andPandemic Alert Period can reduce co-infections andmight ameliorate pandemic effects. HHS recom-mendations are for enhanced levels of seasonalinfluenza vaccinations in groups at risk for severeinfluenza and healthcare workers. In addition, HHSrecommends enhanced pneumococcal polysaccha-ride vaccination for some individuals.29 A limitedamount of H5N1 avian influenza vaccine is beingstockpiled. However, as the pandemic virus cannotbe predicted, it is unknown if stockpiled vaccine willprovide protection against a future circulating pan-demic influenza virus. A monovalent vaccine isexpected to start becoming available within four-to-six months after identification of a specific pan-demic virus strain. As noted above, the HHSPandemic Influenza Plan recommends that health-care workers be included on the priority list (whichhas not been fully defined) when the availability ofpandemic influenza vaccinations is limited.28, 29

References1 Murphy B.R., R.G. Webster 1996. Orthomyxovirus-es. In Fields Virology. Third Edition. Fields B.N.,D.M. Knipe, P.M. Howley, editors. Philadelphia, PA:Lippincott-Raven, New York. pp. 1397-445.2 Perdue, M.L., D.E. Swayne. 2005. Public HealthRisk from Avian Influenza Viruses. Avian Dis 49:317-327. September.3 HHS. 2006. Pandemic Influenza Plan, Appendix C.U.S. Department of Health and Human Services.Last accessed April 12, 2006: http://www.hhs.gov/pandemicflu/plan/appendixc.html.4 CDC. 2005. Pandemic Influenza Key Facts. Centersfor Disease Control and Prevention. Last accessedJune 6, 2006: http://www.cdc.gov/flu/keyfacts.htm.5 HHS. 2005. Pandemic Influenza Plan, Supplement1. U.S. Department of Health and Human Services.Last accessed February 2, 2005: http://www.hhs.gov/pandemicflu/plan/sup1.html.6 HHS. 2005. Pandemic Influenza Plan, Supplement5. U.S. Department of Health and Human Services.Last accessed February 2, 2006: http://www.hhs.gov/pandemicflu/plan/sup5.html.

19 Alford R.H., J.A. Kasel, V. Knight. 1966. Humaninfluenza resulting from aerosol inhalation. ProcSoc Exp Biol Med 122(3):800-804.20 Moser M.R., T.R. Bender, H.S. Margolis, G.R.Nobel, A.P. Kendal, D.G. Ritter. 1979. An outbreak ofinfluenza aboard a commercial airliner. Am JEpidemiol 110(1):1-6. July.21 Bean, B., B.M. Moore, B. Sterner, L.R. Peterson,D.N. Gerding, H.H. Balfour. 1982. Survival of influen-za viruses on environmental surfaces. J Infect Dis146(1):47-51. July.22 Blumenfeld H.L., E.D. Kilbourne, D.B. Louria, D.F.Rogers. 1959. Studies on influenza in the pandemicof 1957-1958. I. An epidemiologic, clinical and sero-logic investigation of an intrahospital epidemic,with a note on vaccination efficacy. J Clin Invest38(1 Part 2):199-212.23 McLean R.L. 1961. General discussion. Am RevRespir Dis 83:36-8.24 HHS. 2005. Pandemic Flu Plan, Supplement 7.U.S. Department of Health and Human Services.Last accessed February 20, 2006: http://www.hhs.gov/pandemicflu/plan/sup7.html..25 MMWR. 2006. Influenza vaccination of healthcare personnel. Last accessed March 21, 2006:http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm.26 Wilde, J.A., et al. 1999. Effectiveness of InfluenzaVaccine in Health Care Professionals. JAMA March10, 1999 – Vol 281, No. 10.27 Salgado C.D., et al. 2004. Preventing NosocomialInfluenza Infection by Improving the VaccineAcceptance Rate of Clinicians. Infection Control andHospital Epidemiology. 2004 Nov: 25(11):923-8.28 HHS. 2005. Pandemic Influenza Plan, Appendix D.U.S. Department of Health and Human Services.Last accessed March 21, 2006: http://www.hhs.gov/pandemicflu/plan/appendixd.html.29 HHS. 2005. Pandemic Influenza Plan, Supplement6. U.S. Department of Health and Human Services.Last accessed March 21, 2006: http://www.hhs.gov/pandemicflu/plan/sup6.html.

7 CDC. 2006. Influenza Clinical Description andDiagnosis. Centers for Disease Control and Pre-vention. Last accessed February 2, 2006: http://www.cdc.gov/flu/professionals/diagnosis/8 HHS. 2005. Pandemic Influenza Plan, Appendix B.U.S. Department of Health and Human Services.Last accessed February 2, 2006: http://www.hhs.gov/pandemicflu/plan/appendixb.html.9 Beigel J.H., J. Farrar, A.M. Ham, et al. 2005. Avianinfluenza A (H5N1) infection in humans. A/H5. NEngl J Med 353(13):1374-85.10 Du Ry van Beest Holle M., et al. 2005. Human-to-human transmission of avian influenza A/H7N7, theNetherlands, 2003. Euro Surveill 1;10(12).11 Walsh E.E., C. Cox, A.R. Falsey. 2002. Clinical fea-tures of influenza A virus infection in older hospital-ized persons. J Am Geriatr Soc 50(9):1498-503.September 8.12 Monto A.S., S. Gravenstein, M. Elliot, M. Colopy,J. Schweinle. 2000. Clinical signs and symptomspredicting influenza infection. Arch Intern Med160(21): 3243-7. November 27. Comments in ArchIntern Med 161(10):1351-2.13 HHS. 2005. Pandemic Influenza Plan. Supplement2: Laboratory Diagnostics. U.S. Department ofHealth and Human Services. Last accessed March21, 2006: http://www.hhs.gov/pandemicflu/plan/sup2.html.14 CDC. 2005. Laboratory Diagnostic Procedures forInfluenza. Last accessed March 21, 2006: http://www.cdc.gov/flu/professionals/labdiagnosis.htm.15 MMWR. 2006. New laboratory assay for diagnos-tic testing of avian influenza A/H5. Morbidity andMortality Weekly Report (MMWR). Last accessedMarch 21, 2006: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5505a3.htm.16 HHS. 2005. Pandemic Influenza Plan, Supplement4. U.S. Department of Health and Human Services.Last accessed February 20, 2005: http://www.hhs.gov/pandemicflu/plan/sup4.html.17 Bridges C.B., M.J. Kuehnert, C.B. Hall. 2003.Transmission of influenza: implications for controlin health care settings. Clin Infect Dis 37(8):1094-1101.18 Schulman J.L. 1967. Experimental transmissionof influenza virus infection in mice: IV. Relationshipof transmissibility of different strains of virus andrecovery of airborne virus in the environment ofinfector mice. J Exp Med 125(3):479-88.

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Guideline for Isolation Precautions in Hospitalswebsite at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html.

Standard PrecautionsStandard precautions should be used for allpatients receiving care, regardless of their diagno-sis or presumed infection status. Standard precau-tions apply to (1) blood; (2) all body fluids, secre-tions, and excretions except sweat, regardless ofwhether or not they contain visible blood; (3) non-intact skin; and (4) mucous membranes. Standardprecautions are designed to reduce the risk oftransmission of microorganisms from both recog-nized and unrecognized sources of infection inhealthcare settings.

A risk assessment to determine necessary PPEand work practices to avoid contact with blood,body fluids, excretions, and secretions will help tocustomize standard precautions to the healthcaresetting of interest. Standard precautions include:

• The use of gloves and facial (nose, mouth, andeye) protection by healthcare workers whenproviding care to coughing/sneezing patients.

• Hand hygiene before and after patient contact,and after removing gloves or other PPE.Routine hand hygiene is performed either byusing an alcohol-based hand rub (preferably)or by washing hands with soap and water andusing a single-use towel for drying hands. Ifhands are visibly dirty or soiled with blood orother body fluids, or if broken skin might havebeen exposed to infectious material, healthcareworkers should wash their hands thoroughlywith soap and water.

• Standard operating procedures to handle anddisinfect patient care equipment, patient rooms,and soiled linen; prevent needlestick/sharpinjuries; and address environmental cleaning,spills-management, and handling of waste.

Poor compliance with standard precautionsamong healthcare workers has been well describedin the scientific literature.3 Additionally, it has notbeen the routine practice of healthcare workers inmany healthcare facilities to wear facial protectionor to encourage respiratory hygiene among patients.

Implementation and enforcement of all standardprecautions, including appropriate use of facial(eyes, nose, and mouth) protection when caring forrespiratory patients, should be prioritized in allhealthcare facilities in order to mitigate pandemicinfluenza transmission.


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Infection ControlA successful infection control program for pandem-ic influenza utilizes the same strategies implement-ed for any infectious agent, including facility andenvironmental controls (i.e., engineering controls),standard operating procedures (i.e., administrativecontrols), personal protective clothing and equip-ment, and safe work practices. These strategiesform the basis of standard precautions and trans-mission-based precautions. Given that the exacttransmission pattern or patterns will not be knownuntil after the pandemic influenza virus emerges,transmission-based infection control strategies mayhave to be modified to include additional selectionsof engineering controls, personal protective equip-ment (PPE), administrative controls, and/or safework practices.

The infection control section of this documentincludes information about standard precautionsand transmission-based precautions as they relateto the protection of healthcare workers.

Standard Precautions andTransmission-Based Precautions

Standard precautions are designed for the care ofall patients, regardless of their diagnosis or pre-sumed infection status. Transmission-based precau-tions are used for patients known or suspected tobe infected or colonized with epidemiologicallyimportant pathogens that can be transmitted by air-borne, droplet, or contact transmission. Someinfectious agents require the application of severaltypes of precautions to prevent transmission. Forexample, HHS/CDC recommends that standard,contact, and airborne precautions be implementedwhen caring for patients with varicella infection.1, 2

Initially designed for the hospital setting, standardprecautions and transmission-based precautionscan be applied to a variety of healthcare settings,including the outpatient environment, the pre-hos-pital setting, and alternate care sites.

The infectious characteristics of pandemicinfluenza will not be known until after it emerges.Consequently, infection control plans will have tobe adapted to the current knowledge of transmis-sion and updated as new information becomesavailable. The Department of Health and HumanServices (HHS) and its partners will provide updat-ed epidemiologic information and infection controlguidance at www.pandemicflu.gov. For a morecomplete discussion of standard precautions andtransmission-based precautions, visit the HHS/CDC

Infectio

nContro

l

Contact PrecautionsIn addition to standard precautions, contact precau-tions are indicated for patients known or suspectedto have serious illnesses easily transmitted bydirect patient contact or by contact with items inthe patient’s environment. In addition to standardprecautions, contact precautions include:

• Putting on PPE (such as gowns) prior to entryinto a patient room and taking off PPE prior toexit.

• Dedicating patient care equipment.• Limiting patient movement.• Placing the patient in a private room or with

patients who have active infection with thesame microorganism or who are suspected tohave active infection with the same microor-ganism but with no other infection (cohorting).

Some studies have shown contact transmissionof human influenza. However, the importance ofthis transmission route remains unknown. Contactprecautions are necessary during aerosol-generat-ing procedures or when contact with infectious flu-ids is anticipated. Whether full contact precautionsare indicated depends on the transmission patternof the emerging pandemic influenza strain. If thepandemic virus is associated with diarrhea, contactprecautions should be added.4

Droplet PrecautionsDroplet precautions are indicated for patientsknown or suspected to have serious illnesses trans-mitted by large particle droplets, such as seasonalinfluenza, invasive Haemophilus influenzae type bdisease and invasive Neisseria meningitidis. Inaddition to standard precautions, droplet precau-tions include the use of a surgical mask when work-ing within 3 feet of the patient and the placement ofthe patient in a private room or with patients whohave an active infection with the same microorgan-ism but with no other infection (cohorting).

Although human seasonal influenza virus is trans-mitted primarily by contact with infectious droplets,some degree of airborne transmission occurs.Additionally, droplet precautions do not protecthealthcare workers from infections resulting fromaerosol transmission or during patient care activitiesthat are likely to generate infectious aerosols, such assputum induction or bronchoscopy.

Airborne PrecautionsAirborne Precautions are designed to reduce therisk of airborne transmission of infectious agents. Inaddition to standard precautions, airborne precau-tions are used for patients known or suspected to

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have serious illnesses. Current clinical guidelinesrecommend that airborne precautions be used forsuch illnesses as H5N1 avian influenza, severeacute respiratory syndrome (SARS), measles, vari-cella, and tuberculosis.1, 5, 6

Airborne precautions include:

• Place patient in a negative pressure room (air-borne infection isolation room) or area, if avail-able.

• If a negative pressure room is not available orcannot be created with mechanical manipula-tion of the air, place patient in a single room.

• If a single room is not available, patients maybe cohorted in designated multi-bed rooms orwards.

• Doors to any room or area housing patientsmust be kept closed when not being used forentry or egress.

• When possible, isolation rooms should havetheir own handwashing sink, toilet, and bathfacilities.

• The number of persons entering the isolationroom should be limited to the minimum num-ber necessary for patient care and support.

• HHS/CDC recommends the use of a particulaterespirator that is at least as protective as aNational Institute for Occupational Safety andHealth (NIOSH)-certified N95.1, 2 For a morecomplete discussion of respirator use duringan influenza pandemic, see the sectionRespiratory Protection for Pandemic Influenzaon page 27.

Airborne precautions against a respiratory illnessshould be implemented, as availability permits,when the circulating pathogen is known to causesevere disease, and the transmission characteristicsof the infecting organism are not well characterized.

For patients for whom influenza is suspected ordiagnosed, surveillance, vaccination, antiviralagents, and use of private rooms as much as feasi-ble is recommended.7 In contrast to tuberculosis,measles, and varicella, the pattern of diseasespread for seasonal influenza does not suggesttransmission across long distances (e.g., throughventilation systems); therefore, negative pressurerooms are not needed for patients with seasonalinfluenza.8 Many hospitals encounter logistic diffi-culties and physical limitations when admittingmultiple patients with suspected influenza duringcommunity outbreaks. If sufficient private roomsare unavailable, consider cohorting patients or, atthe very least, avoid room-sharing with high-riskpatients. For additional information regarding the

airborne infection isolation rooms, see the sectionAirborne Infection Isolation Rooms on page 19.

Compliance with Infection Control

Healthcare administrators should emphasize thoseaspects of infection control already identified as“weak links” in the chain of infectious precau-tions—adherence to hand hygiene, consistent andproper use of PPE, and influenza vaccination ofhealthcare workers. The following section describesfactors influencing compliance with infection con-trol measures. Healthcare employers and employ-ees should work together addressthese factors and enhance compli-ance with infection control recom-mendations.

Hand Hygiene ComplianceAlthough handwashing is well-known as a critical factor for infec-tion control, low rates of healthcareworker compliance have been welldocumented. The HHS/CDCHealthcare Infection ControlPractices Advisory Committee (HIC-PAC), in collaboration with theSociety for Healthcare Epidemiologyof America (SHEA), the Associationfor Professionals in Infection Controland Epidemiology (APIC), and theInfectious Diseases Society ofAmerica (IDSA) reviewed 33 studiesfrom 1981 to 2000. They concludedthat adherence of healthcare work-ers to recommended hand hygieneprocedures has been poor, withmean baseline rates of 5 - 81 percentand an overall average of 40 percent.3

Several factors influence adherence to handhygiene practices, including

• Being a physician or a nursing assistant, ratherthan a nurse

• Wearing gowns/gloves• Understaffing and overcrowding• Handwashing agents that cause irritation and

dryness• Lack of knowledge of guidelines• Perceived lack of institutional priority for hand

hygiene

It is important to recognize that healthcare work-ers report compliance with hand hygiene recom-mendations despite observations to the contrary.Recognition of the factors that influence compli-


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ance to hand hygiene practices is important inorder to enable healthcare employers to prioritizeand customize compliance strategies. These strate-gies should be implemented to promote handhygiene and may include staff education, remindersin the workplace and routine observation and feed-back.

Appendix B contains extended informationregarding risk factors for non-compliance with handhygiene recommendations and strategies for suc-cessful promotion of hand hygiene. For a morecomplete discussion of the recommendations for

hand hygiene and the scientific evi-dence, see the HHS/CDC Guidelinefor Hand Hygiene in HealthcareSettings at http://www.cdc.gov/hand-hygiene/.

Respiratory ProtectionComplianceStudies have shown that healthcareworker compliance rates with respira-tory protection are highly variable.9, 10

Healthcare workers fail to wearrespirators for a number of reasons,and it is important to understand thenature of this resistance in order toovercome it. The following are themost frequently cited reasons for notwearing respirators:11

1. They are hot and uncomfortable.2. They produce “pain spots” ifpoorly fitted.3. They interfere with communica-tion and performance.4. They are not easily accessiblewhen you need them.

5. They put the burden of safety on the wearerrather than the company.6. They make the wearer look “funny,” alarmist, notmacho, or unattractive.7. They produce labored breathing, increased heartrate, and perspiration.8. They impair vision and can actually be a safetyhazard.9. They produce feelings of claustrophobia andanxiety.

The National Institute for Occupational Safetyand Health (NIOSH) has published a guide that pro-vides guidance on developing and implementing arespiratory protection program in the healthcare set-ting, TB Respiratory Protection Program in HealthCare Facilities, September 1999, accessible at http://www.cdc.gov/niosh/99-143.html. Initially intended

Key Messages

Recognition of the factorsthat influence compliancewith with infection controlpractices is important inorder to enable healthcareemployers to prioritizeand customize compliancestrategies.

Compliance strategiesmay include staff educa-tion, reminders in theworkplace and routineobservation and feedback.

Healthcare employers andemployees should worktogether to develop aninstitutional safety climatethat encourages compli-ance with recommendedinfection control practices.

• Cleanliness and orderliness of the worksite• Minimal conflict and good communications

among staff• Frequent safety-related feedback and training

by supervisors• Availability of PPE and engineering controls16

This scale is available in the original referenceand may be useful to assess problem areas of aninstitutional safety climate and increase adherenceto infection control practices. Healthcare employersand employees should work together to develop aninstitutional safety climate that encourages compli-ance with recommended infection control practices.

Facility Design, Engineering, andEnvironmental Controls

Engineering controls are the preferred method toreduce transmission of infectious aerosols in areas

used to house or evaluatepatients with respiratory ill-ness. The appropriate use ofengineering controls andother control efforts willrequire frequent analysis ofpandemic influenza trans-mission patterns in desig-nated wards, in the facility,and in the community.

Existing healthcare facili-ty layouts should be evaluat-ed for potential enhance-ments of infection control.A SARS investigation inOntario17 noted that hospi-tals designed with open,public spaces encounteredlogistical difficulties andgreat expense in their effortsto control entry and, there-fore, to control introductionof infectious diseases.Hospitals had an inadequatenumber of isolation roomsand negative pressurerooms. Triage areas weredesigned to streamlinepatient flow and enhance

patient satisfaction, rather than to prioritize infec-tion isolation or healthcare worker protection.

A desirable emergency room design includes atriage area that can be closed off as an isolationarea, in the event of inadvertent contamination.Isolation areas should have adjacent rooms for staff

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for protection against tuberculosis, the guidance canbe adapted to address a variety of infectiouspathogens, including pandemic influenza.

Healthcare employers should work hard to over-come employee resistance to wearing respiratorsand promote full compliance with the respiratoryprotection program. Strategies should be imple-mented to promote respirator use, such as staffeducation, reminders in the workplace and routineobservation and feedback.

Organizational Factors that AffectAdherence to Infection ControlLessons from the SARS outbreak showed that themost important factors affecting healthcare workerperceptions of risk and adherence to infection con-trol practices were healthcare workers’ perceptionthat their facilities had clear policies and protocols,having adequate training in infection control proce-dures, and having specialistsavailable.12

In a study among 1,716hospital-based healthcareworkers, Gershon et al.(1995) found that employ-ees who perceived a strongcommitment to safety attheir workplace were over2.5 times more likely tocomply with universal pre-cautions.13 Another study ofnurses found that the per-ception of PPE interferencewith work was the strongestpredictor of failure to complywith universal precautions.14

The same researchers exam-ined the relative importanceof safety climate, the avail-ability of PPE, and individualemployee characteristics asdeterminants of compliancewith universal precautions.Safety climate was found tohave the greatest associationwith proper infection controlbehaviors.15

Gershon et al. (2000)developed a safety climate scale (46 questions) tomeasure six different areas of a hospital safety cli-mate:

• Senior management support for safety programs• Absence of workplace barriers to safe work

practices

Key Messages

An influenza pandemic will increase thedemand for hospital inpatient and inten-sive care unit beds and assisted ventilationservices.

Infectious disease and disaster manage-ment experts have predicted the need touse schools, stadiums, and other convert-ed settings in the event of a pandemic thatresults in severe disease.

The National Strategy for PandemicInfluenza calls for communities to antici-pate large-scale augmentation of existinghealthcare facilities.

Limit admission of influenza patients tothose with severe complications of influen-za who cannot be cared for outside thehospital setting.

Admit patients to either a single-patientroom or an area designated for cohortingof patients with influenza.

If possible, and when practical, use of anairborne isolation room may be consid-ered when conducting aerosol-generatingprocedures.

to put on and take off scrubs, and to take showers.Facility planning should include storage space foraugmented infection control items, includingdurable goods such as ventilators, portable high-efficiency particulate air (HEPA) filtration units,portable x-ray units, and respirators.

Thoughtful facility design includes rest and recu-peration sites for responders. These sites can bestocked with healthy snacks and relaxation materi-als (e.g., music and movies), as well as pamphletsor notices about workforce support services.

Facility CapacityAn influenza pandemic may increase the demandfor hospital inpatient and intensive care unit bedsand assisted ventilation services by more than 25percent.18 Toronto clinicians reported that the inten-sive care unit capacity was a key factor that deter-mined the number of SARS patients that could bemanaged. It was determined that approximately 20percent of SARS patients required intensive care;therefore, a maximum number of SARS patientsper facility could be calculated.19

HHS/CDC provided instructions that allow publichealth officials to estimate the demand for hospitalresources and to estimate the number of deaths,both for a 1968-type of influenza pandemic and fora 1918-type of pandemic.20 FluAid 2.0 and FluSurge2.0 software estimate the number of deaths, hospi-talizations, outpatient visits, and the increaseddemand for hospital resources (e.g., beds, intensivecare, or ventilators for both scenarios). For addi-tional information see Appendix A.

Alternate care sites may be developed at federalor state discretion to ease the burden of care onhealthcare facilities. For additional informationregarding alternate care sites, see section AlternateCare Sites on page 47.

Engineering Controls in Improvised SettingsInfectious disease and disaster managementexperts have predicted the need to use schools, sta-diums, and other converted settings in the event ofa pandemic that results in severe disease. TheNational Strategy for Pandemic Influenza21 calls forcommunities to anticipate large-scale augmentationof existing healthcare facilities.

During the SARS outbreak of 2004, the NorthYork General Hospital in Toronto converted twonearly constructed hospital wings into SARS wards.Additionally, a tent clinic was built on an ambu-lance loading dock to triage the general public pre-senting with possible SARS. A more detaileddescription of the converted healthcare settings,

including the implementation of engineering ofcontrols, is available in Loutfy et al. 2004.19

Airborne Infection Isolation RoomsAlthough the need to isolate patients with highlypathogenic infections is a central tenet of infectioncontrol, a large percentage of U.S. hospitals haveno isolation rooms. Only 61.7 percent of hospitalsresponding to the American Hospital Association2004 annual survey reported having an airborneinfection isolation room.22

Airborne infection isolation rooms receivenumerous air changes per hour (ACH) (>12 ACH fornew construction as of 2001; >6 ACH for construc-tion before 2001), and is under negative pressure,such that the direction of the air flow is from theoutside adjacent space (e.g., the corridor) into theroom. The air in an airborne infection isolationroom is preferably exhausted to the outside, butmay be recirculated provided that the return air isfiltered through a high-efficiency particulate air(HEPA) filter.

For more information, consult the HHS/CDCGuidelines for Environmental Infection Control inHealth Care Facilities, available at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.

For care of pandemic influenza patients in thehospital:4

• Limit admission of influenza patients to thosewith severe complications of influenza whocannot be cared for outside the hospital set-ting.

• Admit patients to either a single-patient roomor an area designated for cohorting of patientswith influenza.

• If possible, and when practical, use of an air-borne isolation room may be considered whenconducting aerosol-generating procedures.

Engineering Controls for Aerosol-Generating Procedures for Patientswith Pandemic InfluenzaIf possible, and when practical, use of an airborneisolation room may be considered when conduct-ing aerosol-generating procedures,4, 6 such as thefollowing:

• Endotracheal intubation• Aerosolized or nebulized medication adminis-

tration• Diagnostic sputum induction/collection• Bronchoscopy• Airway suctioning• Positive pressure ventilation via face mask


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(e.g., BiPAP and CPAP)• High-frequency oscillatory ventilation

If a negative pressure room is not available, the fol-lowing strategies may be considered. However,there is only limited scientific evidence to supportthese strategies:6, 23, 24

• Perform the procedure in a private room, sepa-rated from other patients.

• If possible, increase air changes, increase neg-ative pressure relative to the hallway, andavoid recirculation of the room air.

• If recirculation of the air is unavoidable, passthe air through a HEPA filter before recircula-tion.

• Keep doors closed except when entering orleaving the room, and minimize entry to andexit from the room.

CohortingIf single rooms are not available, patients infectedwith the same organisms can be cohorted (sharerooms). These rooms should be in a well-definedarea that is clearly separated from other patientcare areas used for uninfected patients.

During a pandemic, other respiratory viruses(e.g., non-pandemic influenza, respiratory syncytialvirus, parainfluenza virus) may be circulating con-currently in a community. Therefore, to preventcross-transmission of respiratory viruses, wheneverpossible assign only patients with confirmed pan-demic influenza to the same room. Management ofcohort areas should incorporate the following:4

• Designated areas should be used for cohortingpandemic influenza-infected patients. At theheight of a pandemic, laboratory testing toconfirm pandemic influenza is likely to be limit-ed, in which case cohorting should be basedon having symptoms consistent with pandem-ic influenza. Suspected cases of pandemicinfluenza should be housed separately fromconfirmed cases of pandemic influenza.

• Whenever possible, healthcare workers as-signed to cohorted patient care units should beexperienced healthcare workers and shouldnot “float” or be assigned to other patient careareas.

• The number of persons entering the cohortedarea should be limited to the minimum num-ber necessary for patient care and support.

• Limit patient transport by having portable x-rayequipment available in cohort areas, if possible.

• Healthcare workers assigned to cohorted

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patient care units should be aware that pan-demic influenza-infected patients may be con-currently infected or colonized with other path-ogenic organisms (e.g., Staphylococcus aureusand Clostridium difficile) and should usestandard and applicable transmission-basedinfection control precautions to prevent trans-mission of healthcare-associated infections.

Engineering Controls in Diagnostic andResearch LaboratoriesDuring the Pandemic Alert Period, specimens fromsuspected cases of human infection with novelinfluenza viruses should be sent for testing to pub-lic health laboratories with proper biocontainmentfacilities. For example, reverse transcriptase poly-merase chain reaction (RT-PCR) can be done in aBiosafety Level 2 laboratory but highly pathogenicavian influenza and highly pathogenic pandemicinfluenza virus isolation should be conducted in aBiosafety Level 3 laboratory with enhancements orhigher as dictated by an appropriate risk assess-ment.

Additional information on laboratory biocontain-ment is provided in the HHS publication Biosafetyin Microbiological and Biomedical Laboratories.25

Pneumatic tube systems are not advisable to trans-port specimens that may contain a highly patho-genic, live virus. Guidelines on when to send speci-mens or isolates of suspected novel avian orhuman strains to HHS/CDC for reference testing areavailable in Appendix 3 of the HHS PandemicInfluenza Plan at http://www.hhs.gov/pandemicflu/plan/sup2.html#app3.26 The American Society forMicrobiology maintains a list of emergency con-tacts in state public health laboratories.27

Autopsy Rooms for Casesof Pandemic InfluenzaSafety procedures for pandemic influenza-infectedhuman bodies should be consistent with thoseused for any autopsy procedure with potentiallyinfected remains. In general, the hazards of workingin the autopsy room seem to depend more on con-tact with infected material, particularly with splash-es on body surfaces, than to inhalation of infectiousmaterial. However, if the pandemic influenza-infect-ed patient died during the infectious period, thelungs may still contain virus and additional respira-tory protection is needed during procedures per-formed on the lungs or during procedures that gen-erate small-particle aerosols (e.g., use of powersaws and washing intestines).

Specimens should be hand delivered wherepossible. Pneumatic tube systems are not advisableto transport specimens that may contain a highlypathogenic, live virus. For additional informationabout specimen collection, visit WHO’s website athttp://www.who.int/csr/disease/avian_influenza/guidelines/humanspecimens/en/index.html.


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Protective autopsy settings for pandemicinfluenza-infected humans include the use of an air-borne infection isolation room (see the sectionAirborne Infection Isolation Rooms on page 19).Exhaust systems around the autopsy table shoulddirect air (and aerosols) away from healthcareworkers performing the procedure (e.g., exhaustdownward). It is important to use containmentdevices whenever possible (e.g., biosafety cabinetsfor the handling of smaller specimens). Therefore,an examiner conducting postmortem exams ofpandemic influenza-infected patients will use air-borne precautions, including a particulate respira-tor, as is recommended for postmortem exams ofavian influenza-infected patients and SARS-infectedpatients.28

Administrative Controls

Respiratory Hygiene/Cough EtiquetteRespiratory hygiene/cough etiquette, proceduresshould be used for all patients with respiratorysymptoms (e.g., coughing and sneezing). Theimpact of covering coughs and sneezes and placinga mask on a coughing/sneezing patient on the con-tainment of respiratory droplets and secretions oron the transmission of respiratory infections hasnot been quantified. However, any measure thatlimits the dispersion of respiratory droplets shouldreduce the opportunity for transmission. Maskingsome patients may be difficult, in which case theemphasis should be on cough etiquette. The ele-ments of cough etiquette are listed below.

For additional information, see RespiratoryHygiene/Cough Etiquette in Healthcare Settingsat http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm.

Pandemic Influenza Specimen CollectionandTransportAll human specimens of secretions and excretionsshould be regarded as potentially infectious.Healthcare workers who collect or transport clinicalspecimens should consistently adhere to recom-mended infection control precautions to minimizetheir exposure. Potentially infectious specimensshould be placed in leakproof specimen bags fortransport, labeled or color coded for transport andhandled by personnel who are familiar with safehandling practices and spill clean-up procedures.Healthcare workers who collect specimens frompandemic-infected patients should also wear PPEas described for employees performing directpatient care.

Respiratory Hygiene/Cough EtiquetteEducate persons with respiratory illness andcoughing or sneezing to:• Cover their mouths and noses with a tissue

and dispose of used tissues in no-touchwaste containers.

• Use a mask when tolerated, especially dur-ing periods of increased respiratory infec-tion activity in the community.

• Perform hand hygiene after contact withrespiratory secretions and contaminatedobjects or materials (e.g., handwashingwith soap and water, alcohol-based handrub, or antiseptic handwash).

• Stand or sit at least 3 feet from other per-sons, if possible.

Healthcare facilities should promote respira-tory hygiene by:• Posting signs requesting that patients and

family members immediately report symp-toms of respiratory illness on arrival to thefacility and use cough etiquette.

• Posting signs requesting that persons withrespiratory illness refrain from visiting thehealthcare facility if they are not seekingmedical treatment.

• Providing conveniently located masks, tis-sues, and alcohol-based hand rubs for wait-ing areas and patient evaluation areas tofacilitate source control.

• Providing no-touch receptacles for used tis-sue disposal.

• Ensuring that supplies for handwashing(i.e., soap, disposable towels) are consis-tently available where sinks are located.

• Educating healthcare workers, patients,family members, and visitors on the impor-tance of containing respiratory droplets andsecretions to help prevent transmission ofinfluenza and other infections.

PatientTransport within Healthcare FacilitiesInfluenza-infected patients’ respiratory secretionsare the principle source of infectious material inhealthcare settings. Maintaining source control ofpatient secretions will limit the opportunities fornosocomial (in hospital) transmission. The follow-ing methods of source control are consistent withthose recommended for other serious respiratoryinfections (e.g., SARS, avian influenza, and tubercu-losis).4, 28,29

• Surgical and procedure masks are appropriatefor use by pandemic influenza-infected patientsto contain respiratory droplets and should beworn by suspected or confirmed pandemicinfluenza-infected patients during transport orwhen care is necessary outside of the isolationroom/area.

• Limit the movement and transport of patientsfrom the isolation room/area for essential pur-poses only. Inform the receiving area/facility assoon as possible, prior to the patient’s arrival,of the patient’s diagnosis and of the precau-tions that are indicated. Use mobile diagnosticservices (e.g., mobile X-ray and CT scan) whenavailable.

• If transport outside the isolation room/area isrequired, the patient should wear a surgicalmask and perform hand hygiene after contactwith respiratory secretions.

• If the patient cannot tolerate a mask (e.g., dueto the patient’s age or deteriorating respiratorystatus), instruct the patient (or parent of pedi-atric patient) to cover the nose and mouth witha tissue during coughing and sneezing, or usethe most practical alternative to contain respi-ratory secretions. If possible, instruct thepatient to perform hand hygiene after respira-tory hygiene.

• Identify appropriate paths, separated frommain traffic routes as much as possible, forentry and movement of pandemic influenzapatients in the facility, and determine howthese pathways will be controlled (e.g., dedi-cated pandemic influenza corridors and eleva-tors).

• If there is patient contact with surfaces, thesesurfaces should be cleaned and disinfected.

• Healthcare workers transporting unmaskedpatients with suspected or confirmed pandem-ic influenza-infected patients should wear anN95 or higher NIOSH-certified respirator.

Pre-Hospital Care and PatientTransportOutside Healthcare FacilitiesDuring an influenza pandemic, patients will stillrequire emergency transport to a healthcare facility.The recommendations in the table on page 23 aredesigned to protect healthcare workers, includingemergency medical services personnel, during pre-hospital care and transport. These recommenda-tions can be instituted when patients are identifiedas having symptoms consistent with an influenza-like illness or routinely, regardless of symptoms,when pandemic influenza is in the community.

Staff Education andTrainingIt is incumbent upon healthcare employers to edu-cate employees about the hazards to which theyare exposed and to provide reasonable means bywhich to abate those hazards. The independentSARS Commission established by the governmentof Ontario noted that many healthcare staff werenot adequately trained in protecting themselvesagainst infectious agents. The Commission noteddeficiencies in safety training and the proper use ofpersonal protective equipment.30

Effective staff training is consistent with facilitypolicies and reinforces infection control strategies.Support from the healthcare institution at the topmanagement and supervisory levels is essential fora successful program. Examples of educationalgoals and objectives for pandemic infection controlstrategies include:

• Educate healthcare workers about recommend-ed infection control precautions for suspectedor confirmed pandemic influenza-infectedpatients. At a minimum, healthcare workersshould follow contact and droplet precautionsfor all patients with acute respiratory illness.

• Ensure that clinicians know where and how topromptly report a pandemic influenza case tohospital and public health officials.

• Communicate planning strategies that addresswhen confirmed pandemic influenza-infectedpatients have been admitted to the facility,nosocomial surveillance should be heightenedfor evidence of transmission to other patientsand staff.

• Educate healthcare workers and visitors on thecorrect use of PPE and hand hygiene.•• Recommended steps for placement and

removal of PPE and performance of handhygiene.

•• Appropriate procedures to select a particulaterespirator that fits well.

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Occupational Safety and Health Administration

(continued on page 24)

P A N D E M I C I N F L U E N Z A P R E P A R E D N E S S A N D R E S P O N S E G U I D A N C E F O R H E A L T H C A R E W O R K E R S A N D H E A L T H C A R E E M P L O Y E R S

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*The Sentinel Provider Network definition of influenza-like illness is fever (>100°F or 37.8°C) and sore throatand/or cough in the absence of a known cause other than influenza.

Screen all patients for influenza-like illness.* If influenza is suspected, implement the following strategies:

• Optimize the vehicle’s ventilation toincrease the volume of air exchange dur-ing transport. The vehicle’s ventilation sys-tem should be operated in the non-recir-culating mode and should bring in asmuch outdoor air as possible.

• When possible, use vehicles that haveseparate driver and patient compartmentsthat can provide separate ventilation toeach area. In this situation, drivers do notrequire particulate respirators.

• Educate healthcare workers engaged inmedical transport about the risks ofaerosol-generating procedures.

• Notify the receiving facility as soon aspossible, prior to arrival, that a patientwith suspected pandemic influenza infec-tion is being transported to the facility andof the precautions that are indicated.

• Minimize the opportunity for contamina-tion of supplies and equipment inside thevehicle (e.g., ensure that all cabinetryremains closed during transport).

• Continue to follow standard infection con-trol procedures, such as standard precau-tions, recommended procedures for wastedisposal and standard practices for disin-fection of the emergency vehicle andpatient care equipment.

• If tolerated by the patients, place a surgicalmask on all patients with respiratory ill-ness to contain droplets expelled duringcoughing. If this is not possible (i.e., wouldfurther compromise respiratory status, oris difficult for the patient to wear), havethe patient cover the mouth and nose witha tissue when coughing, or use the mostpractical alternative to contain respiratorysecretions.

• Healthcare workers transporting patientswith influenza-like illness should use a res-pirator (N95 or higher). If respirators arenot available, healthcare workers shouldwear a surgical mask.

Without relying on patient screening, routinely implement the following strategies:

• Optimize the vehicle’s ventilation toincrease the volume of air exchange dur-ing transport. The vehicle’s ventilation sys-tem should be operated in the non-recir-culating mode and should bring in asmuch outdoor air as possible.

• When possible, use vehicles that haveseparate driver and patient compartmentsthat can provide separate ventilation toeach area. In this situation, drivers do notrequire particulate respirators.

• Educate healthcare workers engaged inmedical transport about the risks ofaerosol-generating procedures.

• Notify the receiving facility as soon aspossible, prior to arrival, that a patientwith suspected pandemic influenza infec-tion is being transported to the facility andof the precautions that are indicated.

• Minimize the opportunity for contamina-tion of supplies and equipment inside thevehicle (e.g., ensure that all cabinetryremains closed during transport).

• Continue to follow standard infection con-trol procedures, such as standard precau-tions, recommended procedures for wastedisposal and standard practices for disin-fection of the emergency vehicle andpatient care equipment.

• Consider routine use of surgical or proce-dure masks for all patients during trans-port when pandemic influenza is in thecommunity.

• Healthcare workers transporting patientsshould use a respirator (N95 or higher). Ifrespirators are not available, healthcareworkers should wear a surgical mask.

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•• Train persons who will be likely to use partic-ulate respirators on how to put them on andhow to perform user seal checks.

• Provide respiratory etiquette educational mate-rials and supplies to coughing individuals.

• Train infection control monitors to observe andcorrect deficiencies in healthcare worker andvisitor adherence to proper hygiene and PPEuse.

• Use simulations (i.e., “table top” or other exer-cises) to test the facility’s response capacities.The exercise should be realistic and shouldcontinue until limiting factors and deficienciesare identified.

• Develop risk communication materials forhealthcare workers, patients, and patient fami-lies/visitors.

Staff education and training should be available informats accessible to individuals with disabilitiesand/or limited English proficiency; and should alsotarget the educational level of the intended audi-ence.

Care of the Deceased Follow standard facility practices for care of thedeceased. Practices should include standard pre-cautions for contact with blood and body fluids. Formore information regarding care of deceased, seeAvian Influenza, Including Influenza A (H5N1), inHumans: WHO Interim Infection Control GuidelineFor Health Care Facilities, April 24, 2006, availableat: http://www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1/en/.

Patient DischargeIf the patient is discharged while possibly still infec-tious, family members should be educated on handhygiene, cough etiquette, the use of a surgical orprocedure mask by a patient who is still coughingand any additional infection control measures iden-tified in forthcoming guidance or recommenda-tions. Updated guidance and recommendations willbe posted on www.pandemicflu.gov whenever theybecome available.

Visitor PoliciesVisitors should be strictly limited to those necessaryfor the patient’s well-being and care, and should beadvised about the possible risk of acquiring infec-tion. Care of patients in isolation becomes a chal-lenge when there are inadequate resources, orwhen the patient has poor hygienic habits, deliber-ately contaminates the environment, or cannot beexpected to assist in maintaining infection control

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precautions to limit transmission of microorgan-isms (e.g., children, patients with an altered mentalstate, or elderly persons). Such patients should bemanaged on a case-by-case basis, balancing therights of the patient with the risk they may presentto others.

• Visitors should be provided PPE to complywith recommended precautions and shouldbe instructed on how to properly put on, takeoff, and dispose of PPE. They should also beinstructed on proper hand hygiene practicesprior to entry to the patient isolation room/area.

• Communication of policies and procedures tovisitors should be available in formats accessi-ble to individuals with disabilities and/or limit-ed English proficiency; and should also targetthe educational level of the intended audience.

• Legal guardians of pediatric patients shouldbe allowed, when possible, to accompany thepatient throughout the hospitalization.

• Parents/relatives/legal guardians may assist inproviding care to pandemic influenza-infectedpatients in special situations (e.g., lack ofresources, pediatric patients, etc.) if adequatetraining and supervision of PPE use and handhygiene is ensured.

• Because family members may have beenexposed to pandemic influenza via the patientor similar environmental exposures, all familymembers and visitors should be screened forsymptoms of respiratory illness upon entry tothe facility.

• Symptomatic family members or visitorsshould be considered possible pandemicinfluenza cases and should be evaluated forpandemic influenza infection.

Healthcare Worker Vaccination

An influenza pandemic occurs when a new versionof an influenza virus develops the capability toinfect humans and to spread easily and rapidlybetween people. Sometimes such new virus ver-sions come from influenza viruses that previouslyaffected only birds or animals, but which havemutated and thus have developed the capabilitiesto infect humans and spread easily among humans.

It is believed that humans will initially have little,if any, immunity to a pandemic influenza virus and,therefore, that everyone will be susceptible to infec-tion. The HHS Pandemic Influenza Plan assumesthat one in five working adults will experience clini-cal disease in a pandemic influenza outbreak.18 Italso presumes that, in an affected community, a

pandemic outbreak will last about 6 to 8 weekswith at least two pandemic disease waves likely tooccur.

Influenza vaccination is the most effectivemethod currently available to prevent people fromgetting infected. During outbreaks of seasonalinfluenza, vaccination against that season’s influen-za subtypes usually prevents infection. If infection isnot fully prevented, a vaccination may lessen theseverity of the resulting illness.

Once a new type of influenza virus emerges, itusually takes four to six months to produce a vac-cine for that virus, using currently available vaccineproduction methods. There may be limited or nopandemic influenza vaccine available for adminis-tration to individuals in the first six months orlonger during a pandemic. However, HHS plans towork with the pharmaceutical industry to produceand stockpile up to 20 million courses of vaccineagainst each circulating influenza virus with pan-demic potential during the pre-pandemic period.31

Stockpiled vaccine will be designated for personnelwho perform critical and essential functions.Medical and public health employees who areinvolved in direct patient contact and other supportservices essential for direct patient care are likely tobe given high priority for receipt of stockpiled vac-cine.32

Annual seasonal influenza immunization ratesamong healthcare workers in the United Statesremain low; coverage among healthcare workers in2003 was 40.1 percent.33 Therefore, to diminishabsence due to illness, it is advisable for healthcarefacilities to encourage and/or provide seasonalinfluenza vaccination for their staff, including volun-teers, yearly, during the months of October andNovember.

Vaccination strategy recommendations for health-care facilities in preparation for or in response to apandemic influenza outbreak include:34

• Promote annual seasonal influenza vaccinationamong staff and volunteers.

• Communicate with state and local healthdepartments as to the availability of stockpilesof vaccine for the specific pandemic influenzasubtype and follow federal and local recom-mendations for administering the vaccine tohealthcare workers.

• Plan for rapid vaccination of healthcare work-ers as recommended by federal agencies andstate health departments, if vaccine for thepandemic influenza virus becomes available.

• Have a system for documentation of influenza


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vaccination of healthcare workers, since vacci-nation for pandemic influenza may require twodoses.

Antiviral Medication for Prophylaxis andTreatment in Healthcare Workers

The HHS Pandemic Influenza Plan assumes thatoseltamivir will be the antiviral medication ofchoice in the event of an outbreak of pandemicinfluenza.31 It assumes that supplies will be limited31

and that the primary source of oseltamivir will befrom federal stockpiles. Oseltamivir can be used totreat persons who are diagnosed with influenza;however, for optimal effectiveness, the treatmentshould be initiated within 48 hours of the onset offlu-like symptoms.

Oseltamivir may also be used prophylactically todecrease the chance of infection in persons, suchas healthcare workers, who have had exposure topandemic influenza patients. Information on theadvisability of using other antiviral medicationsduring an influenza pandemic will be determinedand communicated after the susceptibility of thecausative viral subtype has been studied.

Healthcare facilities should maintain contactwith federal and local health departments concern-ing the availability of antiviral medications and therecommendations to administer antiviral medica-tions as treatment or as prophylaxis to healthcareworkers and emergency medical personnel whohave direct patient contact.34 Regardless of theavailability of antiviral medication, it should not beused in lieu of a full infection control program.

• When considering antiviral prophylaxis, besure to evaluate appropriate candidates forcontraindications, answer their questions,review adverse effects, and explain the risksand benefits.

• Maintain a log of persons on antiviral medica-tions, persons evaluated and not receiving pro-phylaxis, doses dispensed, and adverse effects.

• Periodically evaluate and update antiviral pro-phylaxis policies and procedures.

Occupational Medicine Services

Employee ProtectionTransmission in healthcare facilities was a majorfactor in the spread of SARS during the 2003 globalepidemic. Factors that likely contributed to the dis-proportionate rate of transmission in healthcaresettings included (1) exposure to infectious dropletsand aerosols via use of ventilators, nebulizers,endotracheal intubation, and other procedures and

(2) frequent and prolonged close contact of employ-ees to patients, their secretions, and potentiallycontaminated environments.35 Case recognition andimplementation of appropriate precautions greatlyreduced the risks of SARS transmission. However,even with appropriate precautions, there were iso-lated reports of transmission to healthcare workersin the settings of aerosol-producing procedures andlapses in infection control techniques.29

Healthcare workers are also members of thecommunity, and during seasonal influenza out-breaks their infectious illnesses may or may not berelated to workplace infectious exposures. Seasonalvaccines will not protect against pandemic influen-za, but will help prevent concurrent infection withseasonal influenza and pandemic influenza, whichwill minimize the possibility of reassortment of thevirus. Protective levels of antibodies are usuallydetectable 2 to 4 weeks after vaccination with sea-sonal influenza vaccine. In addition, healthcareworkers who provide direct patient care may beexposed to pandemic influenza viruses. Theseemployees should be monitored for illness andsupported as needed.

Recommendations for Occupational Health Administrators Protecting healthcare workers benefits both the com-munity and the individual employee. Comprehensiveoccupational health programs can limit transmissionfrom infected employees and allow them to continueworking while their services are in extreme demand.

Surveillance Activities• Keep a register of healthcare workers who

have provided care for pandemic influenza-infected patients (confirmed or probablecases).

• Keep a register of healthcare workers whohave recovered from pandemic influenza (con-firmed or probable cases).

• Have a healthcare worker influenza-like illnesssurveillance system in the healthcare facility,including encouragement for self-reporting bysymptomatic healthcare workers.

• Have a system to monitor work absenteeismfor health reasons, especially in healthcareworkers providing direct patient care.

• Screen all healthcare workers providing care topandemic influenza-infected patients forinfluenza-like symptoms before each dailyshift. Symptomatic healthcare workers shouldbe evaluated and excluded from duty.

• Clinical employees believed to have had signif-icant clinical exposure to a highly pathogenicinfluenza strain should be evaluated; counseledabout the risk of transmission to others; andmonitored for fever, respiratory symptoms,sore throat, rhinorrhea (runny nose), chills, rig-ors, myalgia, headache, and diarrhea.

Vaccination and Antivirals• Vaccinate healthcare workers against seasonal

influenza and monitor compliance. • Coordinate with public health officials for local

policy on antiviral prophylaxis of healthcareworkers and assistance for obtaining adequatesupplies of neuraminidase inhibitors for pro-phylaxis of healthcare workers providing carefor pandemic influenza-infected patients.28

Develop a system to provide neuraminidaseinhibitors to healthcare workers exposed topandemic influenza-infected patients accordingto local and national policies.

Occupational Medical Surveillance andStaffing DecisionsOccupational health played a major role in deter-mining which healthcare workers should return towork during the SARS outbreaks.19 In future out-breaks, individual risk assessment and fitness forduty determinations should be accomplished moreefficiently with the support of updated staff medicalrecords and with serologic testing results, if available.

• If possible, perform serologic and other testingfor pandemic influenza on healthcare workerswith influenza-like illness and who have hadlikely exposures to pandemic influenza-infectedpatients.

• Healthcare workers with serological evidenceof pandemic influenza infection should haveprotective antibodies against this strain andcan be prioritized for the care of pandemicinfluenza patients. These employees couldalso be prioritized to provide care for patientswho are at risk for serious complications frominfluenza (e.g., transplant patients and neonates).However, be aware that subsequent “waves”of influenza infection may be caused by a dif-ferent influenza strain.

• Some healthcare workers have an increasedrisk of complications due to pandemic influen-za (e.g., pregnant women, immunocompro-mised persons and persons with respiratorydiseases). Care should be taken to provideappropriate education, training and policies

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that comply with federal, state and local lawsto adequately protect these employees.

• Healthcare workers who are ill should not beinvolved in direct patient care since they maybe more vulnerable to other infections andmay be more likely to develop severe illness ifinfected with pandemic influenza. In addition,ill healthcare workers can transmit their illnessto vulnerable patients.

Personal Protective Equipment

GlovesHHS recommends the use of gloves made of latex,vinyl, nitrile, or other synthetic materials as appro-priate, when there is contact with blood and otherbodily 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.

Because glove supplies may be limited in theevent of pandemic influenza, other barriers such asdisposable paper towels should be used whenthere is limited contact with respiratory secretions,such as handling used facial tissues. Hand hygieneshould be practiced consistently in this situation.4

Gowns4

• Healthcare workers should wear an isolationgown when it is anticipated that soiling ofclothes or uniform with blood or other bodilyfluids, including respiratory secretions, mayoccur. HHS states that most routine pandemicinfluenza patient encounters do not necessitatethe use of gowns. Examples of when a gownmay be needed include procedures such asintubation or when closely holding a pediatricpatient.

• Isolation gowns can be disposable and madeof synthetic material or reusable and made ofwashable cloth.

• Gowns should be the appropriate size to fullycover the areas requiring protection.

• After patient care is performed, the gownshould be removed and placed in a laundryreceptacle or waste container, as appropriate.Hand hygiene should follow.

Goggles/Face Shields The HHS Pandemic Influenza Plan does not recom-mend the use of goggles or face shields for routine

contact with patients with pandemic influenza;however, if sprays or splatters of infectious materialare likely, it states that goggles or a face shieldshould be worn as recommended for standard pre-cautions.4 For additional information about eye pro-tection for infection control, visit NIOSH’s websiteat http://www.cdc.gov/niosh/topics/eye/eye- infectious.html.

If a pandemic influenza patient is coughing, anyhealthcare worker who needs to be within 3 feet ofthe infected patient is likely to encounter sprays ofinfectious material. Eye and face protection shouldbe used in this situation, as well as during the per-formance of aerosol-generating procedures.

Respiratory Protection for Pandemic InfluenzaWhile droplet transmission is likely to be the majorroute of exposure for pandemic influenza, as is thecase with seasonal influenza, it may not be the onlyroute. Given the potential severity of health conse-quences (illness and death) associated with pan-demic influenza, a comprehensive pandemicinfluenza preparedness plan should also addressairborne transmission to ensure that healthcareworkers are protected against all potential routes ofexposure. Establishment of a comprehensive respi-ratory protection program with all of the elementsspecified in OSHA’s Respiratory Protection standard(29 CFR 1910.134) is needed to achieve the highestlevels of protection. Additional information on theRespiratory Protection standard is included inAppendix C in this document. More information onthe elements of a comprehensive respiratory pro-tection program and the use of respirators can befound at http://www.osha.gov/SLTC/respiratorypro-tection/index.html.

Healthcare workers are at risk of exposure to air-borne infectious agents, including influenza. Forsome types of airborne infectious agents (such asSARS), healthcare workers are not only at risk forillness but may become a potential source of infec-tion to patients and others. Selection of appropriaterespiratory PPE requires an understanding of theairborne infectious agents, their infectious andaerodynamic properties, the operating characteris-tics of the PPE, and the behaviors and characteris-tics of the healthcare workers using the PPE. Manydifferent types of respiratory PPE are available toprotect healthcare workers, each with a different setof advantages and disadvantages.

There will continue to be uncertainty about themodes of transmission until the actual pandemicinfluenza strain emerges. It is expected that therewill be a worldwide shortage of respirators if andwhen a pandemic occurs. Employers and employ-


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and the person’s face. A proper seal between theuser’s face and the respirator forces inhaled air tobe pulled through the respirator’s filter material andnot through gaps between the face and respirator.Surgical masks, however, are not designed to sealtightly against the user’s face. During inhalation,potentially contaminated air can pass through gapsbetween the face and the surgical mask, thusavoiding being pulled through the material of themask and losing any filtration that it may provide.

When personal protective equipment is neces-sary to protect against droplet transmission ofinfectious agents, employees must place a barrierbetween the source of the droplet (e.g., a sneeze)and their mucosal surfaces. Such protection couldinclude a surgical mask to cover the mouth andnose and safety glasses to cover the eyes. Recentstudies show that aerosol penetration through asurgical mask is highly dependent on particle size,mask construction, and breathing flow rate. Onestudy showed that penetration rates for submicronparticles could be as high as 80 percent for surgicalmasks.36 Even relatively unconventional uses (e.g.,the wearing of multiple surgical masks) have beenshown to be less protective than NIOSH-certifiedrespirators. For example, research has shown thatthe use of up to five surgical masks worn by volun-teers results in particle reduction of only 63 percentfor one mask, 74 percent for two masks, 78 percentfor three masks, and 82 percent for five masks,compared with a recommended reduction of atleast 95 percent for properly fitted N95 respirators.37

To help employers and employees better under-stand respirators, the following paragraphs discusstheir construction, classification, and use.

RespiratorsA respirator is a personal protective device that isworn on the face, covers at least the nose andmouth, and is used to reduce the wearer’s risk ofinhaling hazardous gases, vapors, or airborne parti-cles (e.g., dust or droplet nuclei containing infec-tious agents). The many types of respirators avail-able include:

• Particulate respirators that filter out airborneparticles.

• “Gas masks” that filter out chemical gases andvapors.

• Airline respirators that use a hose/pipe to pro-vide a flow of clean air from a remote source.

• Self-contained breathing apparatus that pro-vide clean air from a compressed air tank wornby the user.

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ees should not count on obtaining any additionalprotective equipment not already purchased andstockpiled. Therefore, it is important for healthcarefacilities to consider respiratory protection foressential personnel to assure that employees areready, willing, and able to care for the general pop-ulation.

Surgical Masks and RespiratorsAlthough some disposable respirators look similarto surgical masks, it is important that healthcareworkers understand the significant functional differ-ence between disposable respirators and surgicalmasks.

• Respirators are designed to reduce an individ-ual’s exposure to airborne contaminants, suchas particles, gases, or vapors. An air-purifyingrespirator accomplishes this by filtering thecontaminant out of the air before it can beinhaled by the person wearing the respirator.A type of respirator commonly found in health-care workplaces is the filtering facepiece partic-ulate respirator (often referred to as an “N95”).It is designed to protect against particulate haz-ards. Since airborne biological agents such asbacteria or viruses are particles, they can be fil-tered by particulate respirators. To assure aconsistent level of performance, the respira-tor’s filtering efficiency is tested and certifiedby NIOSH.

• In comparison, surgical masks are notdesigned to prevent inhalation of airborne con-taminants. Their ability to filter small particlesvaries greatly and cannot be assured to protecthealthcare workers against airborne infectiousagents. Instead, their underlying purpose is toprevent contamination of a sterile field or workenvironment by trapping bacteria and respira-tory secretions that are expelled by the wearer(i.e., protecting the patient against infectionfrom the healthcare worker). Surgical masksare also used as a physical barrier to protectthe healthcare worker from hazards such assplashes of blood or bodily fluids. When bothfluid protection (e.g., blood splashes) and res-piratory protection are needed, a “surgicalN95” respirator can be used. This respirator isapproved by FDA and certified by NIOSH.

Another important difference in protecting health-care workers from airborne infectious agents is theway respirators and surgical masks fit the user’sface. Respirators are designed to provide a tightseal between the sealing surface of the respirator

In addition, filters in this family are given a des-ignation of N, R, or P to convey their ability to func-tion in the presence of oils.

“N” if they are Not resistant to oil. “R” if they are somewhat Resistant to oil.“P” if they are strongly resistant (i.e., oilProof).

This rating is important in work settings whereoils may be present because some industrial oilscan degrade the filter performance to the point thatit does not filter adequately. (Note: This is generallynot an issue in healthcare facilities.) Thus, the threefilter efficiencies combined with the three oil desig-nations leads to nine types of particulate respiratorfilter materials:

Recent HHS/CDC infection control guidance docu-ments provide recommendations that healthcareworkers protect themselves from diseases poten-tially spread through the air by wearing a fit testedrespirator at least as protective as a NIOSH-certifiedN95 respirator. Employees can wear any of the par-ticulate respirators for protection against diseasesspread through the air, if they are NIOSH-certifiedand if they have been properly fit tested and main-tained. As noted above, NIOSH-certified respiratorsare marked with the manufacturer’s name, the partnumber, the protection provided by the filter, and“NIOSH.”

Employees who will be exposed to respiratoryhazards other than airborne infectious agents(e.g., gases) should consult the NIOSH RespiratorSelection Logic for more detailed guidance onappropriate respiratory protection at http://www.cdc.gov/niosh/docs/2005-100/default.html.

Particulate respirators can be divided into sever-al types:

• Disposable or filtering facepiece respirators,where the entire respirator facepiece is com-prised of filter material. It is discarded when itbecomes unsuitable for further use due toexcessive breathing resistance (e.g., particulateclogging the filter), unacceptable contamina-tion/soiling, or physical damage.

• Reusable or elastomeric respirators, where thefacepiece is cleaned, repaired, and reused, butthe filter cartridges are discarded and replacedwhen they become unsuitable for further use.

• Powered air-purifying respirators, where a bat-tery-powered blower pulls contaminated airthrough filters, then moves the filtered air tothe wearer.

All respirators used by employees are requiredto be tested and certified by NIOSH. NIOSH usesvery high standards to test and approve respiratorsfor occupational uses. NIOSH-certified particulaterespirators are marked with the manufacturer’sname, the part number, the protection provided bythe filter (e.g., N95), and “NIOSH.” This informationis printed on the facepiece, exhalation valve cover,or head straps. If a respirator does not have thesemarkings and does not appear on one of the fol-lowing lists, it has not been certified by NIOSH.

A list of all NIOSH-certified disposable respira-tors is available at http://www.cdc.gov/niosh/npptl/respirators/disp_part/particlist.html. NIOSH alsomaintains a database of all NIOSH-certified respira-tors regardless of respirator type (the CertifiedEquipment List), which can be accessed at http://www.cdc.gov/niosh/celintro.html.

Classifying Particulate Respirators and Particulate FiltersAn N95 respirator is one of nine types of particulaterespirators. Particulate respirators are also knownas “air-purifying respirators” because they protectby filtering particles out of the air as you breathe.Particulate respirators protect only against parti-cles—not gases or vapors. Since airborne biologicalagents such as bacteria or viruses are particles,they can be filtered by particulate respirators.

Respirator filters that remove at least 95 percentof airborne particles, during “worst case” testingusing the “most-penetrating” size of particle, aregiven a 95 rating. Those that filter out at least 99percent of the particles under the same conditionsreceive a 99 rating, and those that filter at least99.97 percent (essentially 100 percent) receive a 100rating.


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ParticulateRespiratorFilter Type

N95N99N100R95R99R100P95P99P100

Percentage(%) of 0.3 µm

airborneparticles filtered

out

959999.97959999.97959999.97

Notresistant

to oil

XXX

Somewhatresistant

to oil

XXX

Stronglyresistant

to oil (oil-

proof)

XXX

Replacing Disposable RespiratorsOnce worn in the presence of an infectious patient,the respirator should be considered potentially con-taminated with infectious material, and touchingthe outside of the device should be avoided. Uponleaving the patient’s room, the disposable respira-tor should be removed and discarded, followed byproper hand hygiene.

If a sufficient supply of respirators is not avail-able during a pandemic, healthcare facilities mayconsider reuse as long as the device has not beenobviously soiled or damaged (e.g., creased or torn),and it retains its ability to function properly. Data onreuse of respirators for infectious diseases are notavailable. Reuse may increase the potential for con-tamination; however, this risk must be balancedagainst the need to provide respiratory protectionfor healthcare workers.

Reuse of a disposable respirator should be limit-ed to a single wearer (i.e., another wearer shouldnot use the respirator). Consider labeling respira-tors with a user’s name before use to prevent reuseby another individual.

If disposable respirators need to be reused by anindividual user after caring for infectious patients,employers should implement a procedure for safereuse to prevent contamination through contactwith infectious materials on the outside of the res-pirator.

One way to address contamination of the respi-rator’s exterior surface is to consider wearing afaceshield that does not interfere with the fit or sealover the respirator. Wearers should remove the bar-rier upon leaving the patient’s room and performhand hygiene. Face shields should be cleaned anddisinfected. After removing the respirator, eitherhang it in a designated area or place it in a bag.Store the respirator in a manner that prevents itsphysical and functional integrity from being com-promised.

In addition, use care when placing a used respi-rator on the face to ensure proper fit for respiratoryprotection and to avoid unnecessary contact withinfectious material that may be present on theoutside of the mask. Perform hand hygiene afterreplacing the respirator on the face.

Exhalation ValvesSome filtering facepiece (and all elastomeric) respi-rators come equipped with an exhalation valve,which can reduce the physiologic burden on theuser by reducing the resistance during exhalation.An exhalation valve may also increase the user’scomfort by reducing excessive dampness and

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warmth in the mask from exhaled breath. The valveopens to release exhaled breath and closes duringinhalation so that inhaled air comes through the fil-ter. Healthcare workers may wear respirators withexhalation valves unless the patient has a medicalcondition (such as an open wound) for which ahealthcare worker would normally wear a surgicalmask to protect the patient. Similarly, respiratorswith exhalation valves should not be placed on apatient to contain droplets and prevent spread ofinfectious particles; surgical masks can be used forthis purpose.

Powered Air-Purifying RespiratorsPowered air-purifying respirators use HEPA filters,which are as efficient as P100 filters and will protectagainst airborne infectious agents. Powered air-purifying respirators provide a higher level of pro-tection than disposable respirators. Healthcare facil-ities have used higher levels of respiratory protec-tion, including powered air-purifying respirators, forpersons present during aerosol-generating medicalprocedures, such as bronchoscopy, on patients withinfectious pulmonary diseases. When powered air-purifying respirators are used, their reusable ele-ments should be cleaned and disinfected after useand the filters replaced in accordance with the man-ufacturer’s recommendations. All used filtersshould be considered potentially contaminated withinfectious material and must be safely discarded.Powered air-purifying respirators may also increasethe comfort for some users by reducing the physio-logic burden associated with negative pressure res-pirators and providing a constant flow of air on theface. In addition, there is no need for fit testing ofloose-fitting hood or helmet models.

Special Considerations for Pandemic PreparednessIf employers prepare appropriately, respiratory pro-tection against pandemic influenza will be moreeffective. Establishment of a comprehensive respi-ratory protection program with all of the elementsspecified in OSHA’s Respiratory Protection standard(29 CFR 1910.134) is needed to achieve the highestlevels of protection. (See the section OSHAStandards of Special Importance on page 50 andAppendix C-1 of this document) Acquiring ade-quate supplies of appropriate respirators, ensuringthat they fit key personnel, conducting appropriatetraining, and performing other aspects of respirato-ry protection can be accomplished in advance of apandemic influenza outbreak. These measuresshould be repeated annually, prior to a pandemicbeing declared, to assure continued preparedness.

If this is done, and the virus has an element of air-borne transmission, the likelihood that employeeswill be effectively protected will be increased.

• Protection against pandemic influenza requiresa comprehensive approach that includes bothhygienic practices (e.g., handwashing andcough etiquette) and respiratory protection.

• Surgical masks are not considered adequaterespiratory protection for airborne transmis-sion of pandemic influenza. However, FDA-cleared surgical masks are fluid resistant andmay be used for barrier protection againstsplashes and large droplets.

• Respiratory protection requires the use of aNIOSH-certified respirator and implementationof a comprehensive respiratory protection pro-gram that considers the following:•• Use NIOSH-certified respirators that are N95

or higher. When both fluid protection (e.g.,blood splashes) and respiratory protection areneeded, use a “surgical N95” respirator thathas been certified by NIOSH and cleared bythe FDA.

•• Consider elastomeric respirators for essentialemployees who may have to decontaminateand reuse respirators in the event that there isa shortage of disposable respirators.

•• Consider powered air-purifying respirators foressential employees who may have to decon-taminate and reuse respirators, wear respira-tors for prolonged periods of time, beexposed to high-risk procedures (e.g., bron-choscopy), or work in high-risk environments.Loose-fitting hooded powered air-purifyingrespirators have the additional advantage ofnot requiring fit testing.

• Employers, especially those whose employeesare likely to be highly exposed to the flu virus(e.g., healthcare workers), should developand implement a plan, train employees, andpurchase/stockpile respiratory protection inadvance for use during a pandemic since therewill likely be shortages of necessary equipmentduring a real pandemic.

For more information regarding the use of respira-tors and surgical masks during a pandemic see,Interim Guidance on Planning for the Use ofSurgical Masks and Respirators in Health CareSettings during an Influenza Pandemic at http://www.pandemicflu.gov/plan/healthcare/ maskguidancehc.html.


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PPE for Aerosol-Generating Procedures During procedures that may generate increasedsmall-particle aerosols of respiratory secretions,healthcare personnel should wear gloves, gowns,face/eye protection, and N95 respirators, surgicalN95 respirators or other appropriate particulate res-pirators. Respirators must be used within the con-text of a respiratory protection program thatincludes a written program, fit testing, medicalclearance, and training (see the section OSHAStandards of Special Importance and Appendix C-1for more information). Consider the use of an air-borne isolation room when conducting aerosol-generating procedures, whenever possible.4

Examples of procedures that generate aerosolsinclude:6

• Endotracheal intubation• Aerosolized or nebulized medication adminis-

tration• Diagnostic sputum induction• Bronchoscopy• Airway suctioning• Positive pressure ventilation via face mask

(e.g., BiPAP and CPAP)• High-frequency oscillatory ventilation

Additional procedures that may result in aero-solization of respiratory secretions are listed in theWorld Health Organization (WHO) document, AvianInfluenza, including Influenza A (H5N1), in Humans:WHO Interim Infection Control Guideline for HealthCare Facilities Annex 4 at http://www.who.int/csr/disease/avian_influenza/guidelines/infection control1/en/.

Order for Putting on and Removing PPEBased on the risk assessment, several items of PPEmay be needed by healthcare workers when enter-ing the room of a patient infected with known orsuspected pandemic influenza.

When PPE is necessary for the specific situation,HHS/CDC recommends that personal protectiveequipment be put on in the following order:38

• Gown• Respirator (or mask, when appropriate)• Face shield or goggles• Gloves

Upon leaving the room, HHS/CDC recommendsthat PPE be removed in a way to avoid self-contam-ination, as follows:38

• Gloves • Faceshield or goggles

gloves and other PPE.• Healthcare facility leaders should make adher-

ence to hand hygiene an institutional priority.

Other Hygienic Measures Healthcare workers working with pandemic influen-za patients should also take care to:4

• Avoid touching their eyes, nose, or mouth withcontaminated hands (gloved or ungloved) toavoid self-inoculation with the pandemicinfluenza virus.

• Avoid contaminating environmental surfacesthat are not directly related to patient care suchas light switches and doorknobs.

Facility Hygiene—Practices and PolicesWhen handling supplies and equipment contami-nated with blood and other potentially infectiousmaterials, employees must comply with OSHA’sBloodborne Pathogens standard.

Dishes and Eating UtensilsStandard precautions are recommended for han-dling dishes and eating utensils used by a patientwith known or suspected pandemic influenza.4

• Healthcare workers, including housekeepingstaff, should wear gloves when handling pan-demic influenza patients’ trays, dishes, andutensils.

• The healthcare facility should wash reusabledishes and utensils in a dishwasher at the rec-ommended water temperature.

• If disposable dishes and utensils are used,these may be discarded with other generalwaste.

For information regarding recommended watertemperatures, consult the Guidelines forEnvironmental Infection Control in Health-CareFacilities at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.

Linens and LaundryThe following precautions are recommended forhandling linens and laundry that might be contami-nated with respiratory secretions from patients withpandemic influenza:4

• Healthcare workers should place soiled linendirectly into a laundry bag in the patient’s room.The linen should be contained in a manner thatprevents the bag from opening during transportand while in the soiled linen holding area.

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• Gown• Respirator or mask

Remember to always use hand hygiene afterremoving PPE. A printable poster on the sequencesfor putting on and taking off PPE, which can beused for employee training and can be posted out-side respiratory isolation rooms, is available athttp://www.cdc.gov/ncidod/sars/ic.htm.

Work Practices

Hand Hygiene To reduce the risk of becoming infected with influen-za, healthcare workers working with influenzapatients should follow rigorous hand hygienemeasures. The HHS/CDC Guideline for HandHygiene in Healthcare Settings provides the recom-mendations for hand hygiene and the scientificsupport for the recommendations at http://www.cdc.gov/handhygiene.

Basic hand hygiene recommendations that helpprotect healthcare workers working with influenzapatients are:3, 4

• Healthcare facilities should ensure that sinkswith warm and cold running water, plain orantimicrobial soap, disposable paper towels,and alcohol-based hand disinfectants are readi-ly accessible in areas where patient care is pro-vided.

• When hands are visibly dirty or contaminatedwith respiratory secretions, wash hands withsoap (either non-antimicrobial or antimicrobial)and water.

• When washing hands with soap and water, wethands first with water, apply the amount ofproduct recommended by the manufacturer tohands, and rub hands together vigorously forat least 15 seconds, covering all surfaces of thehands and fingers. Rinse hands with water anddry thoroughly with a disposable towel. Use adisposable towel to turn off the faucet.

• If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminatinghands in all clinical situations including con-tact, whether gloved or ungloved, with aninfluenza patient.

• When decontaminating hands with an alcohol-based hand rub, apply product to the palm ofone hand and rub hands together, covering allsurfaces of hands and fingers, until hands aredry. Follow the manufacturer’s recommenda-tions regarding the amount of product to use.

• Always use hand hygiene after removing

• Healthcare workers should wear gloves andgowns when directly handling soiled linen andlaundry (e.g., bedding, towels, and personalclothing), as per standard precautions. Thereshould be no shaking or handling of soiledlinen and laundry in a manner that might cre-ate an opportunity for disease transmission orcontamination of the environment.

• Healthcare workers should wear gloves whentransporting bagged linen and laundry.

• Healthcare workers should perform handhygiene after removing gloves that have beenin contact with soiled linen and laundry.

• The healthcare facility should ensure thatlinens and laundry are washed and dried inaccordance with infection control standardsand procedures.

For additional information, see the section Laundryand Bedding, in Guidelines for EnvironmentalControl in Health-Care Facilities at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.

Patient Care Equipment To protect healthcare workers, standard practicesfor handling and reprocessing used patient careequipment, including medical devices, should befollowed.4

• Healthcare workers should wear gloves whenhandling and transporting used patient careequipment.

• Healthcare workers should wipe heavily soiledequipment with a U.S. Environmental ProtectionAgency (EPA)-approved hospital disinfectantbefore removing it from the patient’s room andfollow current recommendations for cleaningand disinfection or sterilization of reusablepatient care equipment.

• Healthcare workers should wipe external sur-faces of portable equipment (e.g., for perform-ing x-rays and other procedures) in the patient’sroom with an EPA-approved hospital disinfec-tant upon removal from the patient’s room.

For additional information, see the sectionEnvironmental Services, in Guidelines forEnvironmental Control in Health-Care Facilities athttp://www.cdc.gov/ncidod/dhqp/gl_environinfec-tion.html.

Environmental Cleaning and DisinfectionHealthcare workers should use precautions whencleaning the rooms of pandemic influenza patientsor of influenza patients who have been dischargedor transferred.4

Cleaning and Disinfection of Patient-Occupied Rooms

• Wear gloves in accordance with facility policiesfor environmental cleaning.4

• Wear a surgical mask in accordance withdroplet precautions.4 Use a respirator when air-borne precautions are warranted by the cir-cumstances.

• Gowns are usually not necessary for routinecleaning of an influenza patient’s room.4

However, a gown must be worn when cleaninga patient’s room if soiling of the employee’sclothes or uniform with blood or other poten-tially infectious materials may occur.

• Wear face and eye protection if cleaning within3 feet of a coughing patient.

• Keep areas within 3 feet of the patient free ofunnecessary supplies and equipment to facili-tate daily cleaning.4

• Use any EPA-registered hospital detergent-dis-infectant.4

• Give special attention to frequently touchedsurfaces (e.g., bedrails, bedside and over-bedtables, TV controls, call buttons, telephones,lavatory surfaces including safety/pull-up bars,doorknobs, commodes, and ventilator sur-faces) in addition to floors and other horizontalsurfaces.4

Cleaning and Disinfection after Patient Dischargeor Transfer 4

• Follow standard facility procedures for post-discharge cleaning of an isolation room.

• Clean and disinfect all surfaces that were incontact with the patient or might have becomecontaminated during patient care.

Disposal of Solid Waste 4

Standard precautions are recommended by HHSfor disposal of solid waste (medical and non-med-ical) that might be contaminated with a pandemicinfluenza virus.

• Contain and dispose of contaminated medicalwaste in accordance with facility proceduresand/or local or state regulations for handlingand disposal of medical waste, including usedneedles and other sharps, and non-medicalwaste.

• Discard used patient care supplies that are notlikely to be contaminated (e.g., paper wrap-pers) as routine waste.

• Healthcare workers should wear disposablegloves when handling waste and should prac-tice hand hygiene after removal of gloves.


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Laboratory PracticesFollow standard facility and laboratory practices forthe collection, handling, and processing of labora-tory specimens.4 Follow airborne precautions whenengaging in aerosol-generating procedures forspecimen collection, such as diagnostic sputuminduction.

References 1 HHS. Centers for Disease Control and Prevention,Atlanta, Georgia. Garner JS, Hospital InfectionControl Practices Advisory Committee. Guidelinefor isolation precautions in hospitals. Infect ControlHosp Epidemiol 1996; 17:53-80.2 Garner JS, Guideline for isolation precautions inhospitals. Part I. Evolution of isolation practices,Hospital Infection Control Practices AdvisoryCommittee. Am J Infect Control 1996; 24:24-52.3 HHS. Centers for Disease Control and Prevention(CDC) Guideline for Hand Hygiene in Health-CareSettings. MMWR. October 25, 2002/51 (RR16); 1-44.4 HHS. 2005. Pandemic Influenza Plan, Supplement4. U.S. Department of Health and Human Services.Last accessed February 20, 2005:www.hhs.gov/pandemicflu/plan/sup4.html.5 CDC, Interim Recommendations for InfectionControl in Healthcare Facilities Caring for Patientswith Known or Suspected Avian Influenza, May 21,2004, http://www.cdc.gov/flu/avian/professional/infect-control.htm.6 HHS. CDC, Public Health Guidance forCommunity-Level Preparedness and Response toSevere Acute Respiratory Syndrome (SARS)Version 2 Supplement I: Infection Control inHealthcare, Home, and Community Settings, III.Infection Control in Healthcare Facilities May 3,2005 accessed 4/11/2006 at http://www.cdc.gov/ nci-dod/sars/guidance/I/healthcare.htm.7 HHS. Centers for Disease Control and Prevention(CDC) Guidelines for the Prevention of Health-Care-Associated Pneumonia. MMWR, March 26, 2004 /53(RR-03);1-36.8 HHS. Interim Guidance on Planning for the Use ofSurgical Masks and Respirators in Health CareSettings during an Influenza Pandemic. October2006. Accessed 3/7/07 at www.pandemicflu.gov/plan/healthcare/maskguidancehc.html.9 Kellerman SE, Saiman L, San Gabriel P, Besser R,Jarvis WR. Observational study of the use of infec-tion control interventions for Mycobacterium tuber-culosis in pediatric facilities. Pediatr Infect Dis J.2001 Jun;20(6):566-70.

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10 Ofner-Agostini, et al., Cluster of Cases of SevereAcute Respiratory Syndrome Among TorontoHealthcare Workers After Implementation ofInfection Control Precautions: A Case Series InfectControl Hosp Epidemiol 2006; 27: 473-478.11 HHS. Public Health Service, Centers for DiseaseControl and Prevention, National Institute forOccupational Safety and Health, TB RespiratoryProtection Program in Health Care FacilitiesAdministrator’s Guide, September 1999.12 Imai, et al., SARS risk perceptions in healthcareworkers, Japan. Emerg Infect Disease 2005; 11: 404-410.13 Gershon RRM, et al. Compliance with universalprecautions among health care workers at threeregional hospitals. Am J Infect Control 1995;23:225-36.14 DeJoy DM, et al. The influence of employee,job/task, and organizational factors on adherence touniversal precautions among nurses. Int J IndErgon 1995;16:43-55.15 DeJoy DM, et al. Behavioral-diagnostic analysis ofcompliance with universal precautions amongnurses. J Occup Health Psychol 2000;5:127-41.16 Gershon RR, et al. Hospital safety climate and itsrelationship with safe work practices and workplaceexposure incidents. Am J Infect Control 2000;28:211-21.17 SARS Key Learnings from the Perspective ofUniversity Health Network, Notes for the CampbellCommission, Available at:http://www.uhn.ca/uhn/corporate/community/docs/campbell_presentation_100103.pdf. 18 HHS. Pandemic Influenza Plan, Part 1, StrategicPlan, November 2005 Available at http://www.hhs.gov/pandemicflu/plan/part1.html.19 Loutfy, et al., Hospital Preparedness and SARS,Emerg Inf Dis, Vol. 10, No. 5, May 2004. p 771-776.20 Centers for Disease Control and Prevention,Instructions to Estimate the Potential Impact of theNext Influenza Pandemic Upon Locale Y, Availableat http://www.cdc.gov/flu/pandemic/impactesti-mate.htm; accessed 6/19/06.21 National Strategy for Pandemic Influenza:Implementation Plan, November 2005, Available athttp://www.whitehouse.gov/homeland/pandemic-influenza-implementation.html. 22 AHA Hospital Statistics 2006 edition, HealthForum LLC.

31 HHS. 2005. Pandemic Influenza Plan. Part II. Sup7. November.32 HHS. 2005. Pandemic Influenza Plan, Appendix D.U.S. Department of Health and Human Services.Last accessed March 21, 2006: www.hhs.gov/pan-demicflu/plan/appendixd.html.33 Centers for Disease Control and Prevention (CDC).Interventions to increase influenza vaccination ofhealthcare workers—California and Minnesota.MMWR Morb Mortal Wkly Rep. 4;54(8):196-9, Mar2005. www.cdc.gov/mmwr/preview/mmwrhtml/mm5408a2.htm.34 HHS. 2005. Pandemic Influenza Plan. Part II. Sup6. November.35 Varia, M, et al. Investigation of a nosocomial out-break of severe acute respiratory syndrome (SARS)in Toronto, Canada. CMAJ 2003; 169(4):285-292.36 Chen CC, Willeke K. Aerosol penetration throughsurgical masks. Am J Infect Control 1992; 20(4):177-184.37 Derrick JL, Gomersall CD. Protecting healthcarestaff from severe acute respiratory syndrome: filtra-tion capacity of multiple surgical masks. J HospInfect 2005; 59(4):365-368.38 HHS. CDC Poster: Sequence for Donning andRemoving Personal Protective Equipment (PPE)(May 7, 2004) accessed 4/11/2006 athttp://www.cdc.gov/ncidod/sars/ic.htm.


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23 Mead K, Johnson D. An evaluation of portablehigh-efficiency particulate air filtration for expedientpatient isolation in epidemic and emergencyresponse. Ann Emerg Med 2004; 44: 635-645.24 Rosenbaum R, et al., Use of a portable forced airsystem to convert existing hospital space into amass casualty isolation area. Ann Emerg Med 2004;44: 628-634.25 Biosafety in Microbiological and BiomedicalLaboratories (BMBL), 4th edition, May, 1999,http://bmbl.od.nih.gov/, accessed 6/23/06.26 HHS. Pandemic Influenza Plan Supplement 2Laboratory Diagnostics. Available athttp://www.hhs.gov/pandemicflu/plan/sup2.html.27 State Public Health Laboratories EmergencyContact List November 2005. Available athttp://www.asm.org/ASM/files/LeftMarginHeaderList/DOWNLOADFILENAME/000000000527/LabStateContacts.pdf.28 World Health Organization. Avian Influenza,including Influenza A (H5N1), in Humans: WHOInterim Infection Control Guideline for Health CareFacilities. Revised April 24, 2006. Accessed onAugust 23, 2006 at http://www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1/en/.29 CDC. Public Health Guidance for CommunityLevel Preparedness and Response to Severe AcuteRespiratory Syndrome (SARS) January 8, 2004,Supplement C: Preparedness and Response inHealthcare Facilities, pp. 1-34., Available at: http://www.cdc.gov/NCIDOD/SARS/guidance/C/index.htm.30 SARS Commission Interim Report SARA andPublic Health in Ontario, April 15, 2004, http://www.sarscommission.ca/report/Interim_Report.pdf.

Pandemic InfluenzaPreparednessAn influenza pandemic is projected to have aworldwide impact on morbidity and mortality, thusrequiring a sustained, large-scale response that hasthe potential to quickly overwhelm hospitals andthe healthcare system regionally and nationally.Because an influenza pandemic may quickly over-whelm the healthcare community (hospitals, outpa-tient clinics, the pre-hospital environment, nursinghomes, assisted living centers, and private homehealthcare) planning should address: (1) internalcontinuation of care and (2) coordination of servic-es with local, state, and federal healthcare agencies.Healthcare resources are not easily shared orredistributed; a pandemic will magnify and strainresources on a much larger scale. Collaborationwith state and federal partners is vital to ensurethat healthcare facilities have assistance with con-sumables, medication, and vaccines during thepandemic.1, 2, 3

This section addresses pandemic planningissues affecting healthcare personnel, the mostvaluable resource in a pandemic crisis.1, 2, 3 It isbeyond the scope of this document to give specificdetails on resource management for individualhealthcare settings. Instead, comprehensive plan-ning for these issues, such as surge capacity, facili-ty space management, and consumable anddurable equipment utilization should be developedin coordination with local, state, and federal agen-cies. There are several checklists, toolkits, andguidelines that will assist healthcare providers andservice organizations in planning for a pandemicoutbreak available at http://www.pandemicflu.gov/plan/healthcare/index.html. For additional influenzapandemic planning resources, see the Appendixsection of this document.

Healthcare Facility Responsibilities During Pandemic Alert Periods

In the event of a pandemic, HHS/CDC will coordi-nate support and intelligence with U.S. publichealth departments regarding the pandemic situa-tion in the U.S. and in foreign countries. TheHomeland Security Council (HSC) National Strategyfor Pandemic Influenza Implementation Plan hasidentified stages for federal government actionsduring a pandemic. The stages are based onspread of the virus in other countries and in theUnited States. These stages can be incorporatedinto healthcare pandemic planning to identify trig-gers for implementation of different aspects of the

facility plan. Below is a broad outline of pandemicplanning for healthcare facilities based on stages ofthe Homeland Security Council National Strategyfor Pandemic Influenza Implementation Plan andthe HHS Pandemic Influenza Plan recommenda-tions.1,4

Healthcare Facility Responsibilities Before aPandemic (HSC Stages 0, 1)

• Develop planning and decision making strate-gies for responding to pandemic influenza. •• Define roles for disaster response, including

responsibility for coordination of a pandemicplan. For example, identify the individualswithin your organization who will be respon-sible for coordinating communications, inte-grating public health recommendations,establishing security, and developing a writ-ten plan.

•• Note that individual circumstances may affectspecific facilities (e.g., rural vs. urban medicalfacilities, hospital vs. pre-hospital and generalpractices vs. specialized medical facilities).

• Understand how to access state and federalinformation and supplies, and to ensure com-munication with local, state, and federal healthand security agencies. Identify supply chainissues and develop alternatives as needed(e.g., overseas sources).

• Develop written plans that address disease sur-veillance, isolation and quarantine practices,hospital capacity criteria, hospital communica-tion, staff education and training, triage, clinicalevaluation and diagnosis, security, facilityaccess, facility infrastructure (e.g., isolationrooms), occupational health for employees,use and administration of vaccines and antivi-ral drugs, facility surge capacity (e.g., durableand consumable supplies), supply chains (pur-chase, distribution and transportation of sup-plies), access to critical inventory supplies, andmortuary issues (e.g., storage capacity). This isnot a comprehensive list. Planning should betailored to the specific facility and community.

• Work with local, state and national emergencyplanning committees to integrate with commu-nity, state and national pandemic plans andtraining.

• Participate in pandemic influenza responseexercises and drills on local and, if possible,state and federal levels. Incorporate lessonslearned into the pandemic disaster responseplans.

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Healthcare Facility Responsibilities During thePandemic (HSC Stages 2 – 5)If there are confirmed human outbreaks overseas(Stages 2 – 3):

• Heighten institutional surveillance of patientsand facility/clinic staff for influenza-like illness.

• Prepare to activate institutional pandemicinfluenza plans, as necessary.

• Establish communications with local, state, andfederal agencies regarding surveillance issuesand recommendations.

If pandemic influenza begins in or enters theUnited States (Stages 4 – 5):4

• Activate institutional pandemic influenza plansto protect staff and patients.

• Heighten institutional surveillance of patientsand facility/clinic staff for influenza-like illness.

• Implement surge capacity plans to sustainhealthcare delivery.

• Identify and isolate potential pandemic influen-za patients.

• Implement infection control practices to pre-vent influenza transmission and monitor staffand patients for nosocomial transmission.

• Ensure rapid and frequent communicationwithin healthcare facilities and between health-care facilities, state health departments, andthe federal government.

• Ensure that there is a process for reportinginfluenza cases and fatalities.

Healthcare Facility Recovery and Preparationfor Subsequent Pandemic Waves (HSC Stage 6)

• Continue institutional surveillance of patientsand facility/clinic staff for influenza-like illness.

• Return to normal facility operations as soon aspossible.

• Review pandemic influenza plan based onexperience during the first pandemic wave.Incorporate lessons learned into preparationfor subsequent pandemic waves.

• Identify and anticipate resource and supplychain issues.

• Continue to emphasize communication withinhealthcare facilities and between healthcarefacilities, state health departments, and the fed-eral government to identify subsequent pan-demic waves.

Incorporating Pandemic Plans intoDisaster Plans

Hospitals already address emergency managementplans as part of the Joint Commission onAccreditation of Healthcare Organizations (JCAHO)standards. Standards EC.4.10 and EC4.20 addressemergency management and require hospitals toconduct a hazard vulnerability analysis as a firststep in disaster planning. A hazard vulnerabilityanalysis allows hospitals to assess the type, proba-bility, impact, and severity of specific hazards anddisasters. This information allows hospitals toanticipate the effects of these events and facilitatescustomized planning and resource stockpiling.Specific information on conducting a hazard vulner-ability analysis can be obtained though the JointCommission Resources, an affiliate of JCAHO.5, 6

In 2003, the National Hospital AmbulatoryMedical Care Survey reported that about 97 percentof surveyed hospitals had plans for responding tonatural disasters and 85 percent had plans torespond to bioterrorism events. Although 75.9 per-cent reported cooperative planning with other facili-ties, only 46.1 percent had written Memoranda ofUnderstanding regarding acceptance of patientsduring a disaster. The survey revealed that hospi-tals drilled for natural disasters more than for ter-rorism events and drilled even less for severe epi-demics.7 Despite recommendations and require-ments for disaster planning, some institutions maybe unprepared for a pandemic event. To addressthis concern, healthcare institutions should consid-er incorporating pandemic influenza planning intodisaster planning by developing an algorithm thatwould group biologic agents with similar character-istics (i.e., smallpox, plague, influenza, severeacute respiratory syndrome (SARS)).3 Plans shouldaddress some key differences in biological disasterplans and influenza pandemic plans.

Pandemic Planning for Support of Healthcare Worker StaffAlthough a pandemic will be a nationwide event, itwill be experienced on a local level. An importantdifference between pandemic planning and masscasualty planning is the understanding that duringan influenza pandemic, hospital staff will be a limit-ed resource, without an opportunity for replenish-ment from other communities. Plans must addressprotection of this vital and critical resource.Planning assumptions in the National Strategy forPandemic Influenza Implementation Plan include a30 percent attack rate in the U.S. population, 50


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percent of those ill will seek medical attention, andan absenteeism rate of up to 40 percent. For infor-mation regarding planning assumptions, seehttp://www.pandemicflu.gov/plan/pandplan.html.These assumptions could also be adapted for localpandemic planning purposes to address hospitalstaffing shortages and surge requirements.1

Define Essential Staff and Hospital Services Defining essential staff and services is typically oneof the first and most vital steps in pandemic plan-ning. During a pandemic, non-pandemic hospitalservices such as trauma care, obstetrics, cardiaccare, and psychiatry will still need to be provided ora referral service made available. Hospitals need to

identify crucial administrative staff, food servicesstaff, housekeeping, security, and facilities staff.Once these essential personnel and positions areidentified, consider implementing cross-training toensure that these processes will continue. Also,identify and develop methods and policies in com-pliance with federal, state and local requirementsfor keeping nonessential staff out of the facilitysuch as through reassignment, administrative leaveor furlough policies. However, even if an individ-ual’s position is considered nonessential, these per-sonnel may be cross-trained and utilized as a con-tingency workforce.3, 4, 8, 9, 10

Physicians and nurses with crucial knowledge ofinfectious disease, pulmonary medicine and criticalcare medicine will need to be identified. Nurses arecurrently an understaffed profession; in a pandemicsituation, this shortage will be even more pro-nounced. Consider how to maximize nursing careby estimating the number of staff needed to carefor a single patient or multiple patients, and thenplan how to meet those needs when there is anincrease in patients or a decrease in staff. Medicaland nursing students may be a potential resourceto meet staffing shortages and to extend care. TheHHS Pandemic Influenza Plan advises that patients’family members could be used in an ancillaryhealthcare capacity. Identify other critical care per-sonnel such as respiratory therapists, pharmacists,laboratory employees, blood bank and morguestaff. To prepare for staffing shortages, considercross-training staff for essential areas such as theemergency department or intensive care units.4, 8, 9, 10

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Influenza Pandemic Planning Issues• Healthcare facilities may have more warn-

ing time and response time for pandemicinfluenza, especially if the initial outbreakdevelops in another country. Mass casualtyand weapons of mass destruction eventsare typically a surprise.

• Influenza pandemic is not a contained orlocal event. Since it is widespread, less fed-eral, state and local support is available atthe individual facility level.

• Unlike a mass casualty or weapons of massdestruction event, emphasis on cohortingpractices, isolation practices, and steriliza-tion procedures is more important for pan-demic infection control than decontamina-tion.

• An influenza pandemic is a sustained crisis.Expect the response to have a longer dura-tion (12 to 24 months).

• Unlike an isolated mass casualty scenario,a pandemic may come and go in waves,each of which can last for six to eightweeks.

• Prevention options (vaccine) and treatmentoptions (medications) are fewer and moreuncertain for pandemic influenza. A vaccinewill likely not be available early in the pan-demic. Antiviral medication is in short sup-ply, is highly susceptible to resistance, andmay not be effective.

• Due to the uncertainty of the nature of pan-demic, pandemic plans must be flexiblewith integrated processes for reviewingcurrent recommendations and updating theplan accordingly.

Essential Personnel and Processes• Designate a multidisciplinary planning

committee responsible for pandemic preparedness and response.

• Empower managers and planners with the authority and resources to formulatepolicies, implement training and enforcework practices to protect employees andpatients.

• Identify essential facility staffing and func-tions.

• Recognize deficiencies such as potentialstaffing shortages, lack of written guide-lines and develop targets for improvement.

• Prepare contingency plans to address criti-cal services.

• Cross-train individuals for leadership rolesand to identify a contingency workforce.

Human Resources Hospital staff and healthcare workers will be a limit-ed resource during a pandemic influenza outbreakdue to illness and/or absenteeism. There will be aneed for people with healthcare training, of anylevel, to meet the increased demands on the localhealthcare community. Begin working with otherfacilities and clinics to develop Memorandums ofUnderstanding for staffing support. Work withthese medical clinics to ensure that healthcareworkers in the community are aware of institutionplanning, protocols and training. Provide communi-cation infrastructure to ensure that practitioners inthe community have the resources to integrate withlarger facilities.1, 4, 8

Healthcare employers should be prepared tosupport existing employees and to accommodatean influx of new providers, both volunteers andrecruited individuals. Healthcare facilities shouldwork with JCAHO and state medical boards toensure an expedited but legal credentialingprocess. A potential resource for personnel aug-mentation is state Emergency Systems forAdvance Registration of Health ProfessionsVolunteers (ESAR-VHP). These state systems arebeing developed in partnership with HHS to regis-ter, classify and verify credentials of potential healthprofessional volunteers in each state (http://www.hrsa.gov/esarvhp/) Local Medical Reserve Corpsunits may also be sources of volunteer health pro-fessional personnel in the immediate vicinity of afacility (http://www.medicalreservecorps.gov/HomePage).1, 4

Pandemic influenza planners should also addressworkers’ compensation issues in advance, includ-ing workplace injuries and illness to volunteers andnew recruits working in response to a pandemic.Experience during the SARS outbreak showed thatwages and salary issues may also arise as health-care workers are requested to work with infectiouscases.8, 9 Workplace issues arising in the context ofa pandemic (e.g., reassignment, payment of wagesor salaries, voluntary or involuntary sick leave,delegation of work duties) should be resolved incompliance with federal, state, and local laws,including equal employment opportunity laws.

Human resources should be involved in plan-ning for other employee support concerns such asthe possible need for housing, meals, places to rest,and child care services. Prepare and plan how thehealthcare facility will provide these services inplanning stages so that during a crisis, employeeswill already have this information.11

Information Technology During a pandemic situation, communication capa-bilities to provide risk communications internal andexternal to facilities are essential. Adequate com-munication infrastructure (computers, Internet, andradios) will ensure that providers, patients andcommunity resources can exchange accurate, time-ly information about the situation. Equipmentshould be tested to ensure compatibility with emer-gency services, law enforcement, security and pub-lic health. Inability to communicate effectivelybecause of technology incompatibility could resultin further strain on the healthcare system andhealthcare workers.12, 13, 14

It is anticipated that during an influenza pan-demic the members of the healthcare communitywill increase their reliance on information technolo-gies. Quarantine requirements during the SARSoutbreak made it difficult for hospital staff to receivecurrent information about the outbreak situation,particularly changing treatment strategies, and rec-ommendations for personal protective measures.The cancellation of medical rounds and businessmeetings further exacerbated the lack of personalcommunications. E-mail, telephone conferences,and Internet access enabled healthcare providers toaccess treatment specialists external to the facility,and obtain the information required to maintain themost current standards of care from public healthexperts. Once these processes were in place,healthcare providers were able to address effectivepatient treatment and personal protective meas-ures. Pandemic planning should address the antici-pated increased reliance on information technolo-gies and ensure that the communication infrastruc-ture enables healthcare workers to access the mostcurrent recommendations.4, 8, 9, 10, 12, 13, 14, 15

Public Health CommunicationsHealthcare facilities need to develop strong riskcommunications resources as part of pandemicplanning for both the community that they serve


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Human Resources• Identify community volunteer and available

medical support professionals.• Develop processes for training, credential-

ing, and communicating with communityprofessionals.

• Plan for health and compensation concernsof healthcare workers.

and their employees. Risk communications shouldbe available in formats accessible to individualswith disabilities and/or limited English proficiency,and should also target the educational level of theintended audience.

Communication with the community, includingpublic relations and risk communications, will berequired to ensure that the general public is educat-ed in self-care techniques, social distancing andaccess to the appropriate level of care.15 Healthcarefacilities and outpatient clinics should consider tele-phone hotlines and websites to provide healthadvice to the public. Hotlines and websites can edu-cate the public in self-care or direct ill individuals tothe appropriate level of care and decrease the bur-den on healthcare facilities. Healthcare facilities andclinics can also institute follow-up phone or e-mailcommunication to ensure that discharged or home-care patients are adequately managed.1, 4, 15

HHS has developed resources for avian influen-za and pandemic influenza communications usingthe communication science-based message map-ping development process. “Message maps” arerisk communications tools used to help organizecomplex information and make it easier to expresscurrent knowledge. The development process dis-tills information into easily understood messageswritten at a sixth grade reading level. These pan-demic influenza and avian influenza message mapsmay be copied and redistributed on paper or elec-tronically (http://www.pandemicflu.gov/ rcommunication/pre_event_maps.pdf).

During a pandemic there will be rumors andmisinformation that can impact healthcare staff andthe community. Fraudulent information aboutcounterfeit vaccines and antiviral medications maybe circulated via multiple communication sources.1, 16

Malicious misinformation may also be launchedagainst local, state and federal agencies.16 Withouta reliable means to communicate accurate informa-tion, misinformation may adversely impact health-care facilities and the public health infrastructure.

For additional information regarding publichealth communications see:

• Department of Health and Human ServicesPandemic Influenza Plan, Supplement 10, avail-able at http://www.hhs.gov/pandemicflu/plan/sup10.html#I.

• Pandemicflu.gov “Risk Communication” web-site, available at http://www.pandemicflu.gov/news/rcommunication.html.

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Surveillance and ProtocolsSurveillance is a cornerstone of disaster prepared-ness. Healthcare facilities and outpatient clinicsboth need to address and implement the capacityto identify and track influenza-like illness. This capa-bility includes identifying appropriate laboratorycapacity, the ability to conduct epidemiology oninfluenza-like illness and to report collected data tothe appropriate state and federal agencies. Once asurveillance program is established, healthcarefacilities will be able to identify the onset of asevere influenza season, identify biologic weapons(anthrax, plague, etc.) and monitor for pandemicinfluenza and/or other emerging respiratory infec-tions (i.e., SARS, Hantavirus pulmonary syndrome).Healthcare facilities should conduct internal surveil-lance to monitor for nosocomial transmission ofinfluenza to staff and other patients. Internal sur-veillance for nosocomial transmission could beused to identify inadequate infection control prac-tices/procedures.1, 12, 17, 18, 19

Effective disease surveillance depends on coop-eration with local, state, and federal health agenciesto ensure that healthcare facilities have access toinfluenza diagnostic criteria, confirmatory laborato-ry tests, and an understanding of the reportingprocess in the event of an influenza pandemic.Health departments in all fifty states and Chicago,New York City and Washington, D.C. have dedicat-ed influenza surveillance coordinators who pro-mote year-round influenza surveillance. These areimportant resources for both hospitals and clinics.In the outpatient setting, the Sentinel Provider

Information Technology and Public Health Communications

• Develop information technology and com-munication infrastructure.

• Provide effective risk communication tostaff and community.

• Consider implementing hotlines/websites to communicate with the public andemployees.

• Identify misinformation and counter withtimely, accurate information.

• Make communications available in formatsaccessible to individuals with disabilitiesand/or limited English proficiency, and alsotarget the educational level of the intendedaudience.

Network (SPN) is a network of healthcare providerswho report the number of weekly influenza-like ill-ness visits and submit samples for testing. Statepublic health departments can assist outpatientproviders who wish to participate in the surveil-lance program. Healthcare facilities can participatein the Emerging Infections Program (EIP) and NewVaccine Surveillance Network (NVSN). Like theSPN, the EIP and NVSN are administered throughstate health departments and coordinated withfederal agencies such as HHS/CDC. Informationabout participation in these surveillance activities iscoordinated through state health departments.1, 17

Healthcare organizations, hospitals and outpatientclinics at least should develop a process to monitorthe following federal and global sources to obtainthe latest information on seasonal influenza, avianinfluenza, pandemic influenza, and other novel res-piratory illnesses:

• Department of Health and Human Serviceshttp://www.pandemicflu.gov/outbreaks/#ussurv.

• Centers for Disease Control and Preventionhttp://www.cdc.gov/flu/weekly/fluactivity.htm.

• World Health Organizationhttp://www.who.int/csr/disease/influenza/influenzanetwork/en/index.html.

Another important aspect of pandemic planningis establishment of protocols for patient screening,treatment, and flow. Patients with influenza-likesymptoms should be identified as quickly as possi-ble. Planning should include contingencies to iso-late patients with influenza-like illness from otherpatients and staff. Criteria should be developed fortriage, admission, care, and discharge of patients.Additional protocols should be developed to addresspoints of entry into a facility, screening of health-care workers, pharmacy access, emergency med-ical services transport priority, altered standards ofcare, and procedures for handling the deceased.During the SARS epidemic, triage criteria andchanging protocols were a source of confusion andstress for healthcare workers. Staff that are trainedand comfortable with triage, admission, treatmentand discharge criteria, experience reduced stressand provide quality patient care during a crisis.4, 8, 11, 20

Facilities should also develop visitor screeningand access policies for a pandemic. If these policiesare not developed in advance, visitor access becomesa security issue and a source of stress for staff,patients, and families. Visitor policies shouldaddress access to ill family members, particularlypediatric patients, and policies for visitation ofdeceased patients.21 Visitation policies will be easi-


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er for the public to accept if the justification andrationale are explained before a crisis.4, 21

Psychological SupportPsychological and behavioral health support forhospital staff is a recommended part of pandemicplanning.11, 20, 22, 23, 24 Personnel will be exposed topublic education and outreach with the potential forconflicting messages, public health surveillanceefforts, and community containment strategies inaddition to work-related efforts involving mass pro-phylaxis strategies, ethical dilemmas due to short-ages of critical supplies and surges in demand forhealthcare service, and possible work-related stig-ma or maladaptive responses of coworkers due tochanges in work practices or loads. Pandemic plan-ning should address numerous areas of potentialdistress, health risk behaviors, and psychiatric dis-ease amongst healthcare system personnel.

The importance of psychological support forhealthcare staff was illustrated during the SARSoutbreak in Canada. During the initial outbreak inToronto, there was a high perception of risk due tolack of information about infection control, morbidi-ty and mortality.8, 13, 14, 20, 25 Healthcare workers, par-ticularly those working directly with SARS patients,reported feeling afraid, helpless, angry, guilty, andfrustrated. One of study of nurses who treatedSARS patients in Taiwan demonstrated an 11 per-cent rate of traumatic stress reactions, includingdepression, anxiety, hostility, and somatizationsymptoms.26 However, despite the risk, healthcareworkers in Toronto and Asia continued to report towork.8, 13, 20

The psychological impact of SARS was not onlyfelt among personnel directly involved in caring forSARS patients, but also among hospital employeeswho were restricted from work either because theywere not in essential positions or quarantined dueto exposure or illness. Supervisors and employees

Surveillance and Protocols• Develop surveillance capabilities for

influenza-like illness.• Ensure infrastructure for reporting influenza

cases to state and federal agencies.• Develop protocols for transport, triage,

admission, treatment, discharge and otherpatient services.

• Develop visitation policies for ill anddeceased patients.

reported feeling isolated and ineffective, andexpressed relief when reassigned to duties in thefacility. Reintegrating employees back into workwas also difficult. Employees reported feeling disor-ganized and disconnected and reported someresentment between employees who had beenrequired to work and those who had beenremoved.11, 20

The impact of treating SARS cases was not iso-lated to the workplace. In order to protect their fam-ilies, healthcare workers often isolated themselvesat home. Healthcare workers and their familiesreported experiencing ostracism outside the work-place and stated that people in the communitywere afraid to associate with them and their fami-lies.8, 11

Healthcare facilities should plan and implementpsychological resources for hospital staff during andafter a pandemic. If there are adequate resources,facilities should consider extending services toemployee family members.11 The followingresources provide detailed recommendations forincorporating psychological support for healthcareworkers and their families into pandemic planning:

• Supplement 11 of the HHS Pandemic InfluenzaPlan at www.hhs.gov/pandemicflu/plan/sup11.htm/.

• Center for the Study of Traumatic Stress.Mental Health and Behavioral Guidelines forResponse to Pandemic Influenza. http://www.usuhs.mil/psy/CSTSPandemicAvianInfluenza.pdf

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Occupational Health Services Identifying and collaborating with institutionaloccupational health services is vital to effectivepandemic influenza planning. Occupational healthservices can coordinate and participate in a varietyof pandemic influenza preparedness and responseactivities.

Developing and Providing EmployeeScreening for Influenza-Like IllnessOccupational health services can monitor employeeabsentee rates in both the pre-pandemic planningstages and during a pandemic in order to gaugethe impact and progression of the pandemic onthe facility and the community. In the event of aninfluenza pandemic, all staff should be screened forillness before contact with patients or other health-care workers. Planning should include processes toscreen employees, track ill healthcare staff and re-integrate staff back into the workplace after recov-ery.4, 9, 27

A sample screening form is available from theWHO document Influenza A (H5N1): WHO InterimInfection Control Guidelines for HealthcareFacilities, Annex 10 at http://www.who.int/csr/ disease/avian_influenza/guidelinestopics/en/index3.html. The form screens employees for signs andsymptoms of infection over multiple days, provid-ing a mechanism to ensure that exposed individu-als are symptom-free before contact with patientsand staff.

Developing and Providing Immunization andTreatment StrategiesOccupational health services should be preparedto work with state and federal agencies in orderto facilitate pandemic influenza vaccination foremployees and the public. Healthcare facilities andorganizations need be aware of and coordinatewith state pandemic planners to assure access toavailable vaccine.1, 4 The pandemic vaccine mayrequire multiple doses, so occupational health serv-ices should develop a system to identify and recordvaccination status for pandemic vaccine recipients.

In addition to a pandemic influenza vaccineplanning strategy, a current, aggressive vaccinationprogram against seasonal influenza is integral toinstitutional preparedness. An effective seasonalinfluenza program can be adapted for a pandemicvaccination campaign.4

Antiviral medication may be a treatment optionfor ill healthcare staff. To maximize effectiveness,these medications should be given as soon as pos-

Psychological Support• Incorporate psychological support of

healthcare workers into pandemic planning.• Reinforce to healthcare workers their value

and importance to the community.• Consider extending resources to cover fam-

ilies of healthcare workers.• Psychological resources should be offered to

healthcare workers for an extended time peri-od after the pandemic crises has resolved.

sible within 48 hours of the onset of symptoms.Screening for appropriate, early treatment ofinfluenza cases among healthcare workers andessential staff could decrease the duration andseverity of staffing illness and absence. Occupationalhealth services should also be prepared to treatsecondary bacterial infections in healthcare work-ers. Treatment and prophylaxis recommendationswill be determined by HHS, but planning foremployee screening and treatment should beimplemented during the pandemic process.4, 27

Continuing Baseline Occupational HealthServicesDuring an influenza pandemic, protection againstexisting occupational hazards (e.g., bloodbornepathogens and tuberculosis) will need to continue.Pandemic influenza planning should include aprocess to quickly integrate volunteers and recruit-ed staff into healthcare facilities to ensure thathealthcare workers are adequately protected.Despite the demands of a pandemic, infection con-trol practices will still need to be maintained.Bloodborne pathogens exposure control plans, res-piratory protection programs, and tuberculosisscreening must be continued during an influenzapandemic. New staff and volunteers should beincluded in these programs to ensure facility andemployee safety and health.

TrainingTraining for a pandemic is essential to ensure con-tinued effective operation of the facility. Cross-train-ing and volunteer training for essential functionsshould be initiated early in pandemic preparednessplanning. If advance training is not an option, then


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ensure that protocols and resources for just-in-time training are in place. If possible, identify poolsof back-up staff or volunteer staff and began train-ing these individuals in infection control practicesand respiratory protection (including fit testing) toensure smooth integration in the healthcare facilityin the event of a pandemic.

It is important to remember that patient careproviders are not the only personnel that need pan-demic preparedness training. For example, foodservices, housekeeping, information technologists,facility managers and human resources are criticalfunctions and may require pandemic-specific train-ing (i.e., hygiene practices).4, 9

Healthcare facilities should also consider devel-oping training for families of employees. Ensuringthat families of healthcare workers are educatedabout hygiene and disease can protect healthcaresystems and reduce employee absence.11

JCAHO requirements include training and drillsas part of disaster planning. Drilling for a pandemicsituation ensures that facilities are prepared forsurge capacity, supply chains, communication infra-structure, and adequate occupational safety andhealth protocols. Disaster drills allow planners toidentify hidden complications that may arise in theevent of a pandemic.5, 6

SecurityA pandemic crisis will intensify the need for facilitysecurity. Security will be an essential function andadditional personnel may be needed during a pan-demic.1, 2, 4 A pandemic will require facilities to limitaccess and implement isolation measures to sepa-

Occupational Health Services• Incorporate institutional occupational

health services into pandemic prepared-ness.

• Develop surveillance, screening and treat-ment protocols.

• Coordinate with local, state and federalagencies for access and recommendationsfor administration of antiviral medicationsand pandemic influenza vaccination.

• Ensure that all employees and volunteersare safely integrated into the healthcarefacility.

Training• Advance training is essential for facility

pandemic preparedness.• Identify critical functions and identify indi-

viduals for training in these functions.• Infection control and use of PPE are appro-

priate training topics in pandemic prepared-ness planning.

• Disaster drills are an optimal approach totesting pandemic preparedness.

• Training should be available in formatsaccessible to individuals with disabilitiesand/or limited English proficiency, andshould also target the educational level ofthe intended audience.

rate potential cases from staff, visitors, and otherpatients. In a pandemic, healthcare facility securitymay need to be ready to address crowd control andphysical protection of the facility and hospital staff.4

Security staff will be interfacing with a scaredand potentially dangerous public. Not only willsecurity personnel be at risk for infection, but theymay have to confront violent individuals demand-ing resources and healthcare. Training and provid-ing personal protective equipment (PPE) is essentialfor these hospital personnel. Facilities should incor-porate training and support for security personnelin the pandemic planning process.

Healthcare facilities should also work with localand federal law enforcement agencies to addressfacility security. Consider preparing security planswith local and state law enforcement. This willallow law enforcement agencies to develop proce-dures for entrance to and egress of from the facility,public access issues, and protection of critical sup-plies. Ensure that law enforcement understandsfacility structure and layout in advance of a crisis.Identify key individuals to liaison with law enforce-ment agencies and coordinate planning and com-munications (i.e., radios). Without adequate securi-ty and the cooperation of law enforcement agen-cies, healthcare facilities may not be able to func-tion during a crisis.

Stockpiles of Essential Resources

An issue that all healthcare facilities must addressas part of pandemic planning is stockpiling re-sources. Due to logistic and economic concerns,this element of disaster planning is often neglected.In 2004, the state of Kentucky conducted a surveyof mass casualty planning in healthcare facilities.

Thirty-eight percent of respondents had emergencyplans that addressed stockpiling antibiotics andsupplies and only 25 percent of hospitals actuallyhad a separate cache of antibiotics for staff in theevent of a bioterrorist event.28

Influenza pandemic planning adds additionalchallenges for disaster stockpiling. An influenzapandemic will be sustained and widespread, andpharmaceutical interventions are currently in shortsupply or nonexistent. These factors limit the abilityof facilities to stockpile pandemic resources. Forthis reason, healthcare facilities should ensure thatpandemic plans address the ability to access local,state and federal stockpiles. Integration with theseresources is vital to ensure distribution and rotationof essential supplies during a crisis.1, 3, 4, 29

HHS has recommended that healthcare facilitiesconsider developing institutional stockpiles ofresources to counter supply shortages and trans-portation issues that may impact the ability toaccess federal and state supplies.4 JCAHO disasterguidance recommends that hospitals have a 48-to-72 hour stand-alone capability;30 however, aninfluenza pandemic may surge through a commu-nity for 6 to 8 weeks. Consequently, stockpile plan-ning will have to balance economic and logisticaldemands with the duration of pandemic waves andhealthcare supplies. Because of resource shortagesand economic concerns, healthcare facilities couldfurther optimize assets by developing coordinatedstockpiles with other local facilities.1

HHS/CDC has medical supplies and medicationsstored in the Strategic National Stockpile (SNS)(http://www.bt.cdc.gov/stockpile). Pandemic anddisaster planning should include working with stateand federal resources to address access to this sup-ply.

Pandemic Influenza Vaccine In the event of a pandemic, it is currently estimatedthat production of initial doses of a vaccine againsta novel strain of influenza would take approximate-ly 4 to 6 months. Influenza vaccines are typicallygrown in fertilized chicken eggs, a process thattakes several months. Federal funding has beenmade available for the development of cell-basedvaccine technologies that have the potential toexpedite the production of a novel influenza vac-cine. In May 2006, HHS awarded contracts totalingmore than $1 billion for development of cell-basedvaccine technologies.1, 31, 32

Pandemic planning should include protocoldevelopment and the stockpiling of supplies foradministering pandemic influenza vaccine.

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Security• Security will be an essential requirement

during a pandemic.• Train security personnel on specific roles

and pandemic scenarios.• Ensure that security personnel have ade-

quate infection control resources.• Integrate facility security with local and

state law enforcement agencies to ensureadequate protection and support of thehealthcare facility and employees.

• Inform and train employees about expectedsecurity measures during a pandemic.

Distribution and vaccination recommendations willbe coordinated through state and local publichealth departments. It is critical that healthcareservices coordinate with these agencies in order toobtain and administer pandemic vaccine.1, 32 HHSwill determine pandemic vaccine recommendationsand prioritization groups (e.g., number of dosesrecommended, indications, contraindications andranking of various groups for priority for immuniza-tion). Current recommendations regarding pan-demic influenza vaccine are available in Part I.Appendix D and in Part II. Supplement 6 of the HHSPandemic Influenza Plan at http://www.hhs.gov/pandemicflu/plan/appendixd.html and http://www.hhs.gov/pandemicflu/plan/sup6.html. Prioritization,based on HHS recommendations, may change.Planning activities should include a process forobtaining and integrating up-to-date pandemicvaccination recommendations.

A vaccine against a pandemic influenza strainmay require two doses to provide adequate immu-nity, therefore, pandemic planning should includedeveloping a procedure to register, track and con-tact individuals who have received immunizations.18,

32, 33 Research is currently being conducted into thedevelopment of more immunogenic vaccines.Vaccines which contain chemical additives calledadjuvants can increase the immune response andrequire the use of less viral protein which couldextend the vaccine supply. Research into othermethods of developing vaccines or vaccine deliverysystems is ongoing, but as of October 2006, nonehave received an FDA license.18, 32, 33

An important part of pandemic planning is insti-tution of an effective, seasonal influenza campaignwhich includes encouraging healthcare workers toget vaccinated for seasonal influenza. Unfortunately,current rates of healthcare worker influenza vacci-nation are not encouraging; only about 40 percentof healthcare workers were vaccinated in 2003.34

Antiviral Medication In contrast to the vaccine, antiviral medications forthe treatment of influenza do not need to be specif-ic to the circulating pandemic strain and, thus, aremore amenable to stockpiling. There are two class-es of antiviral drugs that are U.S. Food and DrugAdministration-approved for the treatment ofinfluenza: the neuraminidase inhibitors (oseltamivirand zanamivir) and the M2 inhibitors (adamantineand rimantadine). Unfortunately, influenza A virus-es can develop resistance to either class of antiviraldrug, and especially rapid emergence of transmissi-ble resistant virus has been reported after treat-


4 5

ment with adamantanes.33, 35, 36 Although hospitalsare encouraged to stockpile these drugs, it isimpossible to predict which medication will appro-priately treat the pandemic virus or if the pandemicvirus will develop resistance to one or both classesof medications. Resistance to amantadine andrimantadine has already occurred in the H3N2seasonal influenza A viruses. As of July 2006, theHHS recommendation for treatment of H5N1 avianand seasonal influenza is to use the medicationoseltamivir.35, 36 Because of worldwide demand,healthcare facilities may have difficulty stockpilingthis medication.

The federal government is building a nationalstockpile with a long-term plan to acquire enoughantiviral medications to treat approximately 25 per-cent of the U.S. population. As of March 2006, therewere approximately 5.5 million treatment regimensof antiviral medication in the SNS and approxi-mately 14 million more were on order. The SNScontains both classes of antiviral drugs, but thelargest stockpiled medication will be the neur-aminidase inhibitor oseltamivir. The targeted SNSlevel is 50 million courses by 2008. The federal gov-ernment also plans to subsidize the states’ pur-chase of an additional 31 million courses.29 Stateallocations from the national stockpile can be foundat http://www.pandemicflu.gov/plan/states/ antivirals.html.

The decision to deploy federal assets from theSNS will be made by HHS officials. Each state andfederal agency will need a designated representa-tive to make emergency requests and coordinatewith HHS to access SNS resources. These repre-sentatives will provide logistic guidance on receiptand distribution of the requested assets. Healthcarefacilities should integrate and communicate withstate planners or there could be difficulty accessingcritical medications.1, 37

Healthcare plans should be developed for theallocation of antiviral medication with the assump-tion of limited supplies. Strategies for treatment willbe outlined by HHS. Recommendations for use ofantivirals may be updated throughout the course ofan influenza pandemic based on epidemiologic andlaboratory data. Pandemic influenza plans shouldincorporate the ability to update and adapt to thelatest HHS guidance. Planning must include meth-ods to screen patients and employees and toensure that these medications are administered in afair manner consistent with HHS recommenda-tions.37, 38, 39

A local plan for distribution, point-of-care loca-

mated that the cost to Ontario province’s healthcaresystem for the SARS outbreak in Toronto wasapproximately $763 million.40, 41

The impact of pandemic influenza would bemuch greater than the impact of SARS. HHS/CDCmodeled a pandemic influenza crisis in the metroAtlanta area with a 25 percent gross attack rate. Themodel estimated that there would be 412 hospitaladmissions a day, with a total of 2,013 cases hospi-talized in one week during the peak of theoutbreak.42 This is about 4.5 times the number ofpatients hospitalized during the Toronto SARS out-break. Although only a model, this example illus-trates how complicated the issue of stockpiles andresources will be during a pandemic. Storage of alarge supply of PPE may be difficult and costly.Some hospitals are working with distributors tohave a stockpile maintained at distributor sites.If there is careful planning for access, transportand delivery of the required PPE, this could be anacceptable option.4

HHS suggests stockpiling the following PPEresources:4

• Disposable N95 respirators, surgical masks• Face shields (disposable or reusable)• Gowns• Gloves

Influenza A (H5N1): WHO Interim InfectionControl Guidelines for Healthcare Facilities, Annex10 (http://www.who.int/csr/disease/avian_influenza/guidelinestopics/en/index3.html) contains additionalconsumable resource recommendations.

Outpatient Services and ClinicsHHS/CDC estimates that in a pandemic, approxi-mately 45 million people with pandemic influenzawill seek outpatient medical care in the UnitedStates (http://www.pandemicflu.gov/plan/pandplan.html). Outpatient clinics should prepare for a surgein utilization of services for pandemic-related illnesswhile continuing to provide medical services fortreatment of other acute and chronic medical condi-tions. Clinics and urgent care centers must identifywhich services can be curtailed in a pandemic andwhich services will need to expand. Optimally, clin-ics should coordinate planning efforts with localhospitals, healthcare organizations and publichealth agencies. Outpatient clinics could serve asresources to augment healthcare facilities or alter-natively, be utilized to reduce the impact on hospi-tals by treating and addressing care for pandemicpatients not requiring hospitalization. Clinics shouldidentify essential personnel and services, identify

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tions and establishment of priority groups is cru-cial. Because of the resource limitations and timeconstraints for efficacy of the medication, develop-ing plans and infrastructure to access, deliver, andprioritize use of this medication must be done inadvance. As with vaccinations, this process shouldbe transparent and healthcare facilities shoulddevelop a risk communication plan that will keepboth healthcare workers and the community updat-ed on current treatment recommendations.37, 38, 39

Stockpiles of antiviral medication may be asecurity issue if there is large pandemic. Considernot only working with hospital security, but alsowith local and state law enforcement officials toensure adequate security during a crisis.

Healthcare facilities should also consider stock-piling additional medications to treat secondaryinfections and pneumonia. Antibiotics and pul-monary medications such as inhalers and nebuliz-ers are stockpile options for treatment and care.Hospitals should arrange for occupational oremployee health clinics to develop distributionplans that address employee illness and exposure.These plans need to be flexible to accommodateHHS guidance for distribution and prioritizationwhen a pandemic virus emerges. Once developed,the policy for using stockpiled supplies and admin-istration of antiviral medications should be trans-parent to employees and the community, includingthe rationale and justification for the policies.

2005 HHS recommendations for antiviral med-ical priority groups can be located in Appendix Dof the HHS Pandemic Influenza Plan at http://www.hhs.gov/pandemicflu/plan/sup7.html.

Personal Protective EquipmentGiven that pandemic influenza vaccine will likelynot be available until 4 to 6 months into the pan-demic and that shortages of antiviral medicationsare anticipated, PPE will be especially important forprotecting healthcare workers. However, logisticand economic considerations may impact theability for healthcare facilities to stockpile PPE. Forexample, the SARS outbreak in Toronto lastedapproximately 6-7 months. One large hospitalreported that at the height of the epidemic the dailyconsumption of PPE equipment included 3,000 dis-posable gowns, 14,000 pairs of gloves, 18,000 N95respirators, 9,500 ear loop masks, and 500 pairs ofgoggles. In the first week of the SARS outbreak, thehospital purchased $1 million worth of supplies,although their annual hospital budget was only $50million per year.9, 40 There were 438 confirmed orsuspected SARS cases in Canada.8 In total, it is esti-

critical supplies and prepare for expanded services.4

Further guidance and information can be found athttp://www.pandemicflu.gov/plan/medical.html.

Outpatient service providers should prepare forstaffing shortages and develop contingency opera-tions plans. Additionally, protocols for triage andeducation of patients should be developed. Inpreparing for an influenza pandemic, HHS recom-mends that clinics stockpile at least one week ofconsumable supplies, including PPE, when there isevidence that a pandemic has begun in the UnitedStates. Performing triage, ensuring social distanc-ing and isolation of potentially infectious patientswill be a challenge in the outpatient care communi-ty. Pandemic phone hotlines and websites can bean option to provide education and self-care forclinic patients in order to avoid unnecessary clinicvisits. Isolation of potentially ill patients could bedifficult; clinics will need protocols and proceduresto maintain appropriate distancing and provideeducation to patients on infection control.43

In addition to providing care for patients, clinicshave the responsibility for ensuring that employeesand healthcare workers are adequately protectedduring an influenza pandemic. Many of these rec-ommendations in this document can be tailored tothe outpatient setting, including these use of appro-priate PPE. Clinics may need to develop respiratoryprotection programs and develop appropriate infec-tion control training for employees. Integration withother clinics and healthcare facilities and publichealth agencies may assist clinics in this process.

Alternate Care Sites Alternate care sites may be developed at federal orstate discretion to ease the burden of care onhealthcare facilities. Some alternate care sites maysupport the community by providing triage andteaching self-care to individuals who are not criti-cally ill. Vaccination and medication distributioncenters may also be opened depending on theavailability of these resources.1, 4 The use anddeployment of these facilities will vary, but therequirement to provide a safe workplace does notdiminish.

It is important that local and state plans addressthese alternate sites and determine adequate train-ing and PPE for employees assigned to these facili-ties. Respiratory protection programs and infectioncontrol programs will need to be developed andimplemented before the facilities are opened to thepublic. Healthcare facilities should consider howthey can facilitate the provision of training and safe-ty resources to the community before a pandemic

situation arises. Primary care providers who haveclinics in the community will need to be trained inthe use of PPE and infection control practices. HHShas developed a checklist to help clinics developpandemic disaster plans (http://www.pandemicflu.gov/plan/medical.html).4 Local and state pandemicplanning should include outreach programs to pro-vide necessary training to these healthcare workers.JCAHO has guidance for the development of surgehospitals at http://www.jointcommission.org/PublicPolicy/surge_hospitals.htm.

References1 HSC. 2006. National Strategy for PandemicInfluenza Implementation Plan, Homeland SecurityCouncil Chapter 6, May.2 Zinkovich L., D. Malvey, et al. 2005. Bioterrorevents: preemptive strategies for healthcareexecutives. Hosp Top, 83(3):9-15.3 Gensheimer, K., M. Meltzer, et al. 2003. Influenzapandemic preparedness. Emerg Infect Dis 9(12):1645-1648. December.4 HHS. 2005. Pandemic Influenza Plan, Supplement3, Healthcare Planning. U.S. Department of Healthand Human Services. 2005.5 OSHA. Best practices for hospital-based firstreceivers of victims from mass casualty incidentsinvolving the release of hazardous substances.OSHA January 2005.6 JCAHO. 2006. Joint Commission on Accreditationof Healthcare Organizations, 2006 HospitalAccreditation Standards for EmergencyManagement Planning, Emergency ManagementDrills, Infection Control, Disaster Privileges. Lastaccessed January 18, 2007: http://www.jointcom-mission.org/NR/rdonlyres/F42AF828-7248-48C0-B4E6-BA18E719A87C/0/06_hap_accred_stds.pdf?HTTP___JCSEARCH.JCAHO.ORG_CGI_BIN_MSMFIND.EXE?RESMASK=MssResEN%2Emskhttp%3A%2F%2Fjcsearch%2Ejcaho%2Eorg%2Fcgi%2Dbin%2FMsmFind%2Eexe%3Fhttp%3A%2F%2Fjcsearch%2Ejcaho%2Eorg%2Fcgi%2Dbin%2FMsmFind%2Eexe%3FRESMASK%3DMssResEN%2Emsk.7 Niska R., C. Burt. 2005. Bioterrorism and masscasualty preparedness in hospitals: United States,2003. National Center for Health Statistics,Hyattsville, MD. Adv Data, no. 364.8 Naylor D., S. Basrur, et al. 2003 Learning fromSARS: A Report of the National AdvisoryCommittee on SARS and public health: 154-154.October.


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9 Loutfy M., T. Wallington, et al. 2004. Hospital pre-paredness and SARS. Emerg Infect Dis 10(5): 771-781. May.10 Hawryluck L., S. Lapindky, T. Steward. 2005.Clinical review: SARS – lessons in disaster manage-ment. Crit Care 9(4): 384-389. August.11 HHS. 2005. Pandemic Influenza Plan, Supplement11, Workforce Support: Psychological Considerationsand Information Needs. U.S. Department of Healthand Human Services. November.12 Johnson M., E. Bone, G. Predy. 2005. Taking careof the sick and scared. Can J Public Health 96(6):412-414. November-December.13 Booth C., T. Stewart. 2005. Severe acute respira-tory syndrome and critical care medicine: TheToronto experience. Crit Care Med 33(1) (suppl.):S53-S60.14 Booth C., T. Stewart. 2003. Communication in theToronto critical care community: important lessonslearned during SARS. Crit Care 7(6): 405-406.December.15 HHS. 2005. Pandemic Influenza Plan, Supplement8, Disease Control and Prevention. U.S. Departmentof Health and Human Services. November.16 U.S. Department of State. United States PursuesCriminal Charges in Bird Flu Drug Fraud. http://usinfo.state.gov/gi/Archive/2006/Jan/23-183730.html23 January 2006. Last accessed January 18, 2007.17 HHS. 2005. Pandemic Influenza Plan, Supplement1, Pandemic Influenza Surveillance. U.S.Department of Health and Human Services.November.18 Gibbs W., C. Soares. 2005. Preparing for a pan-demic. Sci Am. 45-54. November.19 McDonald L.C., Simor A.E., et al. 2004 SARS inHealthcare Facilities, Toronto and Tiwan. EmergInfect Dis. 10(5): 777-781. May.20 Maunder R., J. Hunter, et al. 2003. The Immediatepsychological and occupational impact of the 2003SARS outbreak in a teaching hospital. Can MedAssoc J. 168(10): 1245-1251. May.21 Ovadia K., I. Gazit, et al. 2005. Better late thannever: a re-examination of ethical dilemmas in cop-ing with severe acute respiratory syndrome. J HospInfect 61: 75-79.22 Reissman D., P. Watson, et al. 2006. Pandemicinfluenza preparedness: adaptive responses to anevolving challenge. Journal of Homeland Securityand Emergency Management, 3(2):1-26.

23 CSTS. Mental Health and Behavioral Guidelinesfor Response to Pandemic Influenza. http://www.usuhs.mil/psy/CSTSPandemicAvianInfluenza.pdf.Last accessed January 18, 2007.24 U.S. Department of Veterans Affairs.Psychological First Aid Manual. http://www.ncptsd.va.gov/pfa/PFA.html. Last accessed January 18,2007.25 Rambaldini G., W. Kumanan, et al. 2005. Theimpact of Severe Acute Respiratory Syndrome onmedical house staff. J. Gen Intern Med 20:318-385.26 Chen C.S., H.Y. Wu., et al. 2005. Psychological dis-tress of nurses in Taiwan who worked during theoutbreak of SARS. Psychiatr Serv 56(1): 76-9.27 HHS. 2005. Pandemic Influenza Plan, Supplement4, Infection Control. U.S. Department of Health andHuman Services. November.28 Higgins W., C. Wainright, et al. 2004. Assessinghospital preparedness using an instrument basedon the Mass Casualty Disaster Plan Checklist:Results of a statewide survey. Am J Infect Control32(6): 327-332. 29 HHS. 2006. Pandemic Planning Update A Reportfrom Secretary Michael O. Leavitt. Department ofHealth and Human Services. March 13.30 JCAHO. 2003. Health Care at the Crossroads:strategies for creating and sustaining community-wide emergency preparedness systems. JointCommission on Accreditation of HealthcareOrganizations.31 News Release. May 4, 2006 HHS AwardsContracts Totaling More than $1 Billion to DevelopCell-Based Influenza Vaccine.http://www.hhs.gov/news/press/2006pres/20060504.html. Last accessed January 18, 2007.32 HHS. 2005. Pandemic Influenza Plan, Supplement6, Vaccine Distribution and Use. U.S. Department ofHealth and Human Services. November.33 Monto A., Vaccine and Antiviral Drugs inPandemic Preparedness. Emerg Infect Dis. 12(1);55-60. January.34 MMWR. 2005. Interventions to increase influenzavaccination of health-care workers – California andMinnesota. Morbidity and Mortality Weekly. 54(08):196-199. March 4.35 CDC. 2006. CDC Recommends against the use ofamantadine and rimantadine for the treatment orprophylaxis of influenza in the United States duringthe 2005-06 influenza season. CDC Health Alert,Centers for Disease Control and Prevention. Last

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accessed January 18, 2007: http://www.cdc.gov/flu/han011406.htm.36 WHO. 2006. Avian Influenza, including InfluenzaA (H5N1), in Humans: WHO Interim InfectionControl Guideline for Health Care Facilities. WorldHealth Organization. February 9. Last accessed onJanuary 18, 2007 at http://www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1/en/.37 HHS. 2005. Pandemic Influenza Plan, Supplement7, Antiviral Drug Distribution and Use. U.S.Department of Health and Human Services.November.38 Cinti S. 2005. Pandemic influenza: are we ready?Disaster Manag Response 3:61067.39 Cinti S., C. Chenoweth, A. Monto. 2005. Preparingfor Pandemic Influenza: should hospitals stockpileoseltamivir? Infect Control Hosp Epidemiol 26(11);852-854. November.

40 Friesen S. 2003. The impact of SARS on health-care supply chains. Logistics Quarterly 9(2). Lastaccessed March 28, 2006:www.lq.ca/issues/fall2003/articles/article01.html.41 Osterholm M. 2005. Preparing for the next pan-demic. Foreign Aff. July/August. Last accessedJune 30, 2006: http://www.foreignaffairs.org/20050701faessay84402/michael-t-osterholm/ preparing-for-the-next-pandemic.html.42 FluSurge 2.0 Manual. Last accessed June 30,2006:http://www.cdc.gov/flu/pdf/FluSurge2.0_Manual_060705.pdf.43 Medical offices and clinics pandemic influenzapreparedness checklist. Last accessed August 3,2006 http://www.pandemicflu.gov/plan/medical.html.


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OSHA Standards of Special ImportanceThe role of OSHA is “to assure safe and healthfulworking conditions for working men and women.”1

Employers have a responsibility to furnish employ-ees “a place of employment which is free from rec-ognized hazards that are causing or are likely tocause death or serious physical harm.”1 In addition,employers must comply with occupational safetyand health standards promulgated by OSHA or bya state with an OSHA-approved state plan. (Moreinformation about state occupational safety andhealth programs can be found at http://www.osha.gov/fso/osp/index.html.) OSHA standards applicableto healthcare facilities are addressed in the stan-dards for General Industry. In addition, theRespiratory Protection standard, the PersonalProtective Equipment standard, and the BloodbornePathogens standard have special importance topandemic preparedness and response.

Respiratory Protection Standard - 29 CFR 1910.134

The primary objective of OSHA’s RespiratoryProtection standard is to protect employees againstinhalation of harmful airborne substances or oxy-gen-deficient air. This standard applies to all occu-pational airborne exposures where employees areexposed to a hazardous level of an airborne con-taminant. The inhalation of pathogenic organismsknown to cause human disease is covered by thisstandard.

Employers are required to use feasible engineer-ing controls as the primary means of controlling aircontaminants. Respirators should be used for pro-tection only when engineering controls have beenshown to be technologically or economically infea-sible or while they are being instituted for the con-trol of the hazard.

Healthcare facilities requiring the use of respira-tors must implement a comprehensive respiratoryprotection program. These programs are to beoverseen by a qualified program administrator andhave key elements that include respirator selection,training, medical certification, fit testing, mainte-nance and cleaning, and program review.

Additional information on the RespiratoryProtection standard is included in Appendix C inthis document. Information describing all of the ele-ments of a comprehensive respiratory protectionprogram and the use of respirators can be found athttp://www.osha.gov/SLTC/respiratoryprotection/index.html.

Personal Protective Equipment Standard -29 CFR 1910.132

When engineering controls, work practices, andadministrative controls are infeasible or do not pro-vide sufficient protection, employers must provideappropriate personal protective equipment (PPE)and ensure its proper use. PPE is worn to minimizeexposure to a variety of workplace hazards. PPEcan include protection for eyes, face, head, andextremities. Gowns, face shields, gloves, and respi-rators are examples of commonly used PPE withinhealthcare facilities.

Employers must conduct a workplace hazardassessment to determine if hazards are present thatnecessitate the use of PPE. The employer must ver-ify that the required workplace hazard assessmenthas been performed through a written certificationthat identifies the workplace evaluated; the personcertifying that the evaluation has been performed;the date(s) of the hazard assessment; and, whichidentifies the document as a certification of hazardassessment. Based on the hazard assessment,employers are to select PPE that will protectemployees from the identified hazards. Employeesare to receive training to ensure that they under-stand the hazards present, the necessity of the PPE,and its limitations. In addition, they must learn howto properly put on, take off, adjust, and wear PPE.Finally, employees must understand the propercare, maintenance, and disposal of PPE.

Healthcare employers can receive more infor-mation about the Personal Protective Equipmentstandard at http://www.osha.gov/SLTC/personalprotectiveequipment/index.html.

Bloodborne Pathogens Standard - 29 CFR 1910.1030

OSHA’s Bloodborne Pathogens standard is a regu-lation that protects employees against health haz-ards related to the occupational exposure to blood-borne pathogens. The standard applies to anyemployee who is occupationally exposed to humanblood or certain other potentially infectious materi-als (e.g., pleural fluid, any body fluids visibly con-taminated with blood, any unfixed human tissue ororgan). The Bloodborne Pathogens standard hasprovisions requiring exposure control plans, engi-neering and work practice controls, PPE, hepatitis Bvaccination, hazard communication, training, andrecordkeeping.

Additional information on the BloodbornePathogens standard is available at http://www.osha.gov/SLTC/bloodbornepathogen/index.html.

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OSHA Standards of Special Im

portan

ce

General Duty Clause

In addition to compliance with the hazard-specificsafety and health standards, employers must pro-vide their employees with a workplace free fromrecognized hazards likely to cause death or seriousphysical harm. Employers can be cited for violatingthe General Duty Clause of the OSH Act if they donot take reasonable steps to abate or address suchrecognized hazards.2

References1 OSHA. Occupational Safety and Health Act of1970 (OSH Act).2 29 U.S.C. 654(a)(1).


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Appendix A Pandemic Influenza InternetResources

Federal/State pandemic disaster plan-ning resources; updated as new infor-mation becomes available.

Checklists for specific healthcare serv-ices, hospitals, clinics, home health,long-term care, EMS.

The FluAid program is a resource forstate and local planners to estimaterange of deaths, hospitalizations, andoutpatient visits for a community.

The FluSurge program estimates the impact of a pandemic on thesurge capacity of individual healthcarefacilities, (i.e., hospital beds, ventila-tors).

AHRQ disaster planning website

Issues addressing bed capacity

Opening shuttered hospitals toaddress surge capacity

Conferences to optimize surge capacity

Development of models for emergency preparedness

Emergency preparedness resourceinventory

Altered standards of care in masscasualty event

Alternate site use during an emer-gency

Computer staffing model

Integrating with public health agencies

Bioterrorism and Epidemic ResponseModel

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Department of Health and Human Services

Department of Health and Human Services

Centers for Disease Control and Prevention

Agency for HealthcareResearch and Quality

General Pandemic Planning Resources

http://www.pandemicflu.gov

http://www.pandemicflu.gov/plan/tab6.html

http://www2a.cdc.gov/od/fluaid

http://www.cdc.gov/flu/flusurge.htm

Multiple resources on disaster planningincluding surge capacity, stockpiles, anddeveloping alternate care sites:

http://www.ahrq.gov/browse/bioterbr.htm

http://www.ahrq.gov/research/havbed/

http://www.ahrq.gov/research/shuttered/shuttools.pdf

http://www.ahrq.gov/news/ulp/btbriefs/btbrief3.htm

http://www.ahrq.gov/research/devmodels/

http://www.ahrq.gov/research/epri/

http://www.ahrq.gov/research/altstand/

http://www.ahrq.gov/research/altsites.htm

http://www.ahrq.gov/research/biomodel.htm

http://www.ahrq.gov/research/health/

http://www.ahrq.gov/research/biomodel3/toc.asp#top

http://www.publichealth.va.gov/flu/pan-demicflu.htm

http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_5/en/index.html

http://www.who.int/csr/en/

http://www.fda.gov/oc/opacom/hottopics/flu.html

http://www.astho.org/

http://www.heics.com/

http://www.jointcommission.org/PublicPolicy/ep_guide.htm

http://www.jointcommission.org/PublicPolicy/surge_hospitals.htm

http://www.ahrq.gov/research/biomodel3/

http://www.pandemicflu.gov/vaccine

http://www.hhs.gov/nvpo/pandemics/tabletopex.html

The VA has information on infectioncontrol and other pandemicresources.

International planning strategies andglobal pandemic information

Information on vaccine, antiviralmedication, fraud investigations.

Resources for pandemic planning,including state health departmentlistings and state pandemic plans.

Hospital Emergency IncidentCommand System (HEICS), anexample of an emergency manage-ment plan for healthcare facilities.

Resources for integrations withcommunity disaster planning. Surgehospital planning and implementation.

Part of the Weil/Cornell Bioterrorismand Epidemic Response Module(BERM), specifically addressingplanning for mass prophylaxis.

Up-to-date information on vaccines,medication and tests for pandemicinfluenza.

Tools to assist planning and conduct-ing tabletop exercises for pandemicinfluenza planning.


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Department of Veterans Affairs

World Health Organization

Food and DrugAdministration

Association of Stateand Territorial Health Officials

California

Joint Commissionon Accreditationof HealthcareOrganizations

Agency for HealthcareResearch and Quality

Department of Healthand Human Services

Department of Healthand Human Services

Resources for Coordination with State and Local Agencies

Resources for Medications and Vaccination Information and Planning

Disaster and Pandemic Influenza Tabletop Exercises and Drills

Appendix B Infection Control Communication Tools for Healthcare Workers

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1. Hand Hygiene, Centers for Disease Control and Prevention:MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. Guideline for Hand Hygiene in Healthcare Settingshttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm Posters:http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdfhttp://www.cdc.gov/od/oc/media/pressrel/fs021025.htmhttp://www.cdc.gov/handhygiene/materials.htm

2. PPE Donning and Doffing Procedures, Centers for Disease Control and PreventionPosters:http://www.cdc.gov/ncidod/sars/pdf/ppeposter1322.pdfhttp://www.cdc.gov/ncidod/sars/pdf/ppeposter148.pdf

3. Department of Veterans AffairsPosters:http://www.publichealth.va.gov/InfectionDontPassItOn/index_hand.htmhttp://www.publichealth.va.gov/InfectionDontPassItOn/index_hand_resp.htmhttp://www.publichealth.va.gov/InfectionDontPassItOn/Index_ppe.htm

4. Occupational Safety and Health Administration, guidance on the proper use of PPE:http://www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html

Appendix B-1 Factors Influencing Adherence to Hand Hygiene PracticesReproduced from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. Guideline for Hand Hygiene in Healthcare Settings, Box 1.


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Observed risk factors for poor adherence to recommended hand hygiene practices• Physician status (rather than a nurse)• Nursing assistant status (rather than a nurse)• Male sex• Working in an intensive care unit• Working during the week (versus the weekend)• Wearing gowns/gloves• Automated sink• Activities with high risk of cross-transmission• High number of opportunities for hand hygiene per hour of patient care

Self-reported factors for poor adherence with hand hygiene• Handwashing agents cause irritation and dryness• Sinks are inconveniently located/shortage of sinks• Lack of soap and paper towels• Often too busy/insufficient time• Understaffing/overcrowding• Patient needs take priority• Hand hygiene interferes with healthcare worker relationships with patients• Low risk of acquiring infection from patients• Wearing of gloves/beliefs that glove use obviates the need for hand hygiene• Lack of knowledge of guidelines/protocols• Not thinking about it/forgetfulness• No role model from colleagues or superiors• Skepticism regarding the value of hand hygiene• Disagreement with the recommendations• Lack of scientific information of definitive impact of improved hand hygiene on

healthcare–associated infection rates

Additional perceived barriers to appropriate hand hygiene• Lack of active participation in hand hygiene promotion at individual or institutional level• Lack of role model for hand hygiene• Lack of institutional priority for hand hygiene• Lack of administrative sanction of noncompliers/rewarding compliers• Lack of institutional safety climate

Source: Adapted from Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol

2000;21:381–6.

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Appendix B-2 Elements of Healthcare Worker Educational and Motivational ProgramsReproduced from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. Guideline for Hand Hygiene in Healthcare Settings, Box 2.

Rationale for hand hygiene• Potential risks of transmission of microorganisms to patients• Potential risks of healthcare worker colonization or infection caused by organisms acquired from the patient• Morbidity, mortality, and costs associated with healthcare–associated infections

Indications for hand hygiene• Contact with a patient’s intact skin (e.g., taking a pulse or blood pressure, performing physical exami

nations, lifting the patient in bed) (25,26,45,48,51,53)*• Contact with environmental surfaces in the immediate vicinity of patients (46,51,53,54)*• After glove removal (50,58,71)*

Techniques for hand hygiene• Amount of hand hygiene solution• Duration of hand hygiene procedure• Selection of hand hygiene agents

— Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the hands of personnel. Antiseptic soaps and detergents are the next most effective, and non-antimi-crobial soaps are the least effective (1,398).

— Soap and water are recommended for visibly soiled hands.— Alcohol-based hand rubs are recommended for routine decontamination of hands for all clinical

indications (except when hands are visibly soiled) and as one of the options for surgical hand hygiene.

Methods to maintain hand skin health• Lotions and creams can prevent or minimize skin dryness and irritation caused by irritant contact

dermatitis• Acceptable lotions or creams to use• Recommended schedule for applying lotions or creams

Expectations of patient care managers/administrators• Written statements regarding the value of, and support for, adherence to recommended hand

hygiene practices• Role models demonstrating adherence to recommended hand hygiene practices (399)*

Indications for, and limitations of, glove use• Hand contamination may occur as a result of small, undetected holes in examination gloves

(321,361)*• Contamination may occur during glove removal (50)*• Wearing gloves does not replace the need for hand hygiene (58)*• Failure to remove gloves after caring for a patient may lead to transmission of microorganizations

from one patient to another (373)*

*The numbers in parentheses after some of the elements refer to references in the original MMWR document.


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Appendix B-3 Strategies for Successful Promotion of Hand Hygiene in HospitalsAdapted from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. Guideline for Hand Hygiene in Healthcare Settings, Table 9. Strategies for Successful Promotion of Hand Hygiene in Hospitals.

Strategies for Successful Promotion of Hand Hygiene in Hospitals• Education• Routine observation and feedback• Engineering control

•• Make hand hygiene possible, easy, and convenient•• Make alcohol-based hand rub available (at least in high demand situations)

• Patient education• Reminders in the workplace• Administrative sanction/rewarding• Change in hand hygiene agent• Promote/facilitate skin care for healthcare workers’ hands• Obtain active participation at individual and institutional level• Improve institutional safety climate• Enhance individual and institutional self-efficacy• Avoid overcrowding, understaffing, and excessive workload• Combine several of above strategies

AirborneInfectionIsolation+

Contact

Hand cleaning

• Betweenpatients

• Immediatelyafter gloveremoval

• Wheneverhands may becontaminatedby secretionsor body fluids

• Use an alco-hol-basedhand rub orwash withantimicrobialsoap andwater

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Appendix B-4 Pandemic Influenza Precautions for Veterans Administration Healthcare Facility StaffReproduced with permission from the Department of Veterans Affairs Pandemic Plan, Appendix E-2:Chart of Pandemic Influenza Precautions for VA Healthcare Facility Staff.

Airborne Infection Isolation and Contact Precautions, in addition to Standard Precautions

This combination of precautions offers the best protection for health care facility staff, especially at theonset of a pandemic before transmission patterns are well understood.

Gloves

• When caringfor patients

• When touch-ing areas or handlingitems contaminatedby patients

Gowns

• With patientcontact

Eye protection

• When within 3 feet ofpatient

• With aerosol-generatingprocedures

Respiratoryprotection

• Use fit-testedN95 mask OR positiveair purifyingrespirator(PAPR) or fit-tested elastomericrespirator

Patients • Wear masksduring trans-port.

• Use maskswith elasticstraps; avoidmasks that tieon.

Room

• Negative air-flow privateroom whenpossible

• Air exhaustedoutdoors orthrough high-efficiency fil-tration.

• Door keptclosed.


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Droplet

Hand cleaning

• Betweenpatients

• Immediatelyafter gloveremoval

• Wheneverhands may becontaminatedby secretionsor body fluids

• Use an alco-hol-basedhand rub orwash withantimicrobialsoap andwater

Gloves

• When caringfor patients

• When touch-ing areas or handlingitems contaminatedby patients

Gowns

• Not required

Eye protection

• With aerosol-generatingprocedures

Respiratoryprotection

• Wear surgicalor procedure-type masks in patientrooms orwhen within 3 feet ofpatients;change whenmoist

• Wear fit-tested N95respirator orequivalentwith aerosolgeneratingprocedures

Patients • Wear masksduring trans-port.

• Use maskswith elasticstraps; avoidmasks that tieon.

Room

• Private roomwhen possible

• Door may beopen.

Droplet Precautions, in addition to Standard Precautions

This combination of precautions should be used if droplet transmission appears to be the common modeof transmission or when incapable of using Airborne Infection Isolation and Contact Precautions.

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Who Can Act?

Individuals

What Public Health Measures?

Cleaning hands regularly.

Following respiratory hygienerules (covering the mouth andnose with tissues when coughing or sneezing).

Getting seasonal influenza vaccinations.

Avoiding contact with sick persons—staying at least three to five feet away.

Staying home when sick—fromwork, school, public places.

Wearing masks when sick withinfluenza, if able to tolerate.

Appendix B-5 Public Health Measures Against Pandemic Influenza for Individuals, HealthcareProviders, and OrganizationsReproduced with permission from Department of Veterans Affairs Pandemic Plan, Appendix E-3: Chart of Public Health Measures Against Pandemic Influenza Precautions for Individuals, Health CareProviders, and Organizations.

The measures in the chart below may be important to reduce transmission of pandemic influenza in VAfacilities and other settings.

Why?

Reduces transfer of microorganismsfrom the hands to the eyes, nose, ormouth. Reduces transmission ofmicroorganisms carried on handsfrom person to person.

Prevents dispersal of respiratoryviruses in the air.

Prevents individuals fromgetting/transmitting seasonalinfluenza, which reduces burden onhealth care system, and keeps theindividual well and able to conductdaily business. Reduces likelihoodof genetic reassortment of influenzastrains when a person is infectedwith more than one strain. Helpspeople become accustomed to get-ting vaccinations.

Reduces likelihood of one’s gettingand transmitting influenza.

Reduces transmission of influenzato other persons.

Reduces transmission to others.


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Who Can Act?

Health care providers

Business, community, regional,and national organizations andleaders

What Public Health Measures?

Tracing contacts.

Isolating people with suspected or confirmed influenza.

Quarantining people exposed to influenza.

Wearing personal protectiveequipment—masks or respirators,gowns, gloves, goggles.

Developing, manufacturing, stockpiling, and distributing antiviral medications.

Developing, manufacturing, stock-piling, and distributing vaccine.

Reducing non-essential travel.

Closing schools.

Declaring “snow days” (temporarilyclosing businesses, offices), post-poning public gatherings.

Enabling employees to work from home; makingteleworking/telecommuting possible.

Partitioning space.

Why?

Locates and allows potentiallyexposed persons to be informedand able to take measures to avoidexposing others.

Reduces transmission of influenzato others.

Reduces transmission of influenzato other persons. Because the incubation period of influenza isabout 2 days, quarantine timewould also be short (actual time will be determined by the characteristics of the pandemicinfluenza virus).

Reduces risk of getting influenzaand potential of transmitting it toothers.

Treats influenza or prevents itsspread.

Prevents influenza.

Reduces the number of persons an individual has contact with andslows the spread of influenza fromregion to region.

Children usually have many more close contacts than adults;closing schools greatly reducestransmission of influenza withinschools, within families, and within communities.

Reduces contacts among persons; has potential to reducetransmission.

Reduces contacts among persons; has potential to reducetransmission.

Limiting access to a building orfacility by screening those whoenter for fever, respiratory symp-toms, and possible recent exposure.

Appendix C-1 Respiratory Protection Programs

OSHA Respiratory Protection StandardThe OSHA Respiratory Protection standard (29 CFR1910.134) requires employers to establish andmaintain a respiratory protection program to pro-tect their respirator-wearing employees. Employersmust provide respirators when such equipment isnecessary to protect the health of employees. Therespirator provided must be suitable for its intend-ed purpose. When an employer is required to pro-vide respirators, the employer must establish andmaintain a respiratory protection program.

Respiratory Protection ProgramA respiratory protection program is a cohesive col-lection of worksite-specific procedures and policiesthat addresses all respiratory protection elementsrequired by the standard. For example, a respirato-ry protection program must contain specific proce-dures describing how respirators will be selected,fitted, used, maintained and inspected in a particu-lar workplace. A written program is needed becausehealth and safety programs can be more effectivelyimplemented and evaluated if the procedures areavailable in a written form for study and review.

Also, a written respiratory protection program isthe best way to ensure that the unique characteris-tics of the worksite are taken into account. Develop-ing the written program encourages the employerto thoroughly assess and document informationpertaining to the respiratory hazards to which theiremployees will potentially be exposed, both duringnormal operating conditions and during reasonablyforeseeable emergencies.

A respiratory protection program is required toinclude the following elements (as applicable):

• Procedures for selecting appropriate respira-tors for use in the workplace.

• Fit testing tight-fitting respirators.• Cleaning, disinfecting, storing, inspecting,

repairing, removing from service or discard-ing, and otherwise maintaining respirators.Also, you must establish schedules for theseelements.

• Ensuring adequate air supply, quantity, andflow of breathing air for atmosphere supply-ing respirators.

• Provisions for medical evaluation of employeeswho must use respirators.

• Training employees in the proper use of respi-rators (including putting them on and remov-ing them), the limitations on their use, andtheir maintenance.

• Regularly evaluating the effectiveness of theprogram.

Respiratory Protection Program AdministratorThe employer must designate a program adminis-trator to run the program and evaluate its effective-ness. An individual is qualified to be a programadministrator if he or she has appropriate trainingor experience in accord with the program’s level ofcomplexity. This training or experience is appropri-ate if it enables the program administrator to fulfillthe minimum standard requirements of recogniz-ing, evaluating, and controlling the hazards in theworkplace. For example, if the program requiresair-supplying respirators for use in immediatelydangerous to life or health environments, the pro-gram administrator must have training and experi-ence pertaining to the use of this type of equip-ment. Similarly, if air-supplying respirators are notused and there are no significant respiratory haz-ards at the workplace, someone with less sophisti-cated experience or training might be able to effec-tively serve in this position.

Ultimately, the appropriate qualifications for therespiratory protection program administrator mustbe determined based on the particular respiratoryhazards that exist, or that are reasonably anticipat-ed, at the workplace.

Medical EvaluationsEmployers must medically evaluate their employ-ees’ ability to wear a respirator. Medical evaluationsare required for both positive pressure and nega-tive pressure respirators. Medical evaluation canbe performed by using a medical questionnaire orby performing an initial medical examination thatobtains the same information as the medical ques-tionnaire. Employers must allow the employee tobe evaluated during the employee’s normal work-ing hours or at a time that is convenient to theemployee, and employers are responsible for pay-ing for this service (even if the employee has cover-age under an insurance plan).

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Appendix C Implementation and Planning for Respiratory ProtectionPrograms in Healthcare Settings

Employers must identify a physician or anotherlicensed healthcare professional (PLHCP) to per-form the medical evaluations. Physicians are notthe only healthcare professionals allowed to per-form medical evaluations for respirator use. TheRespiratory Protection standard allows any PLHCPto administer the medical questionnaire (describedbelow) or to conduct the medical examination ifdoing so is within the scope of the PLHCP’s license.Employers may check with PLHCPs in their localarea to see if performing the medical evaluation iswithin the scope of their professional license, oremployers may check with the state’s licensingboard.

The Medical Questionnaire The medical questionnaire is designed to identifygeneral medical conditions that place employeeswho use respirators at risk of serious medical con-sequences. If employers choose to use the medicalquestionnaire to conduct the medical evaluation,they must use the questionnaire contained in theRespiratory Protection standard (Appendix C of thestandard, Part A., Sections 1 and 2). The PLHCPdetermines whether or not Part B of the question-naire needs to be administered, and the PLHCP canalter the questions in Part B in any manner he orshe thinks is appropriate. Employers may choose touse medical examinations in place of the question-naire, but they are not required to do so. Medicalexaminations must be provided for an employeewho gives a positive response to any questionamong questions 1-8 of Part A, Section 2 inAppendix C of the standard. Although the question-naire does not have to be administered during themedical examination, the PLHCP must obtain thesame information from the employee that is con-tained in the questionnaire.

Fit TestingThe Respiratory Protection standard requiresemployers to conduct fit testing on all employeeswho are required to wear a respirator that includesa tight-fitting facepiece. Fit testing is a procedureused to determine how well a respirator “fits”—that is, whether the respirator forms an adequateseal on the user’s face. If a good facepiece-to-faceseal is not achieved, the respirator will provide alower level of protection than it was designed toprovide. For example, without a good seal, the res-pirator can allow contaminants to leak into the face-piece and be inhaled by the user.

There are two types of fit testing: quantitativeand qualitative. Quantitative fit testing is a method

of measuring the amount of leakage into a respira-tor. It is a numeric assessment of how well a respi-rator fits a particular individual. To quantitatively fittest a respirator, sampling probes or other measur-ing devices must be placed to measure aerosolconcentrations both outside and on the inside ofthe respirator facepiece. Qualitative fit testing is anon-numeric pass/fail test that relies on the respira-tor wearer’s response to a substance (“test agent”)used in the test to determine respirator fit. In quali-tative fit testing, after performing user seal checks,the respirator wearer stands in an enclosure anda test agent is introduced, such as banana oil(isoamyl acetate), saccharin, Bitrex, or irritantsmoke (without a test enclosure). If the individualcan smell or taste the test agent (or is irritated bythe smoke), this indicates that the agent leaked intothe facepiece and that the respirator has failed thetest because a good facepiece-to-face seal has notbeen achieved. If the employee cannot successfullycomplete the qualitative test with a particular res-pirator, the employee must then be tested withanother make, size, or brand of respirator.

Fit testing must be conducted for all employeesrequired to wear tight-fitting facepiece respiratorsas follows:

• Prior to initial use.• Whenever an employee switches to a different

tight-fitting facepiece respirator (for example, adifferent size, make, model, or style).

• At least annually.

Employers must ensure that an additional fit testis conducted if an employee experiences a changein physical condition that could affect the seal onthe tight-fitting facepiece respirator. This require-ment is triggered by a physical change:

• Reported by the respirator user.• Observed by the employer, a physician or other

licensed healthcare professional, the supervi-sor, or the program administrator.

• Physical changes in the employee that mightaffect the facepiece-to-face seal could include,for example, an obvious change in bodyweight, facial scarring, dental work, or cosmet-ic surgery.

If, after fit testing, an employee reports that hisor her respirator does not fit properly, you mustallow the employee a reasonable opportunity toselect a different tight-fitting facepiece respirator.After another respirator is selected, you must con-duct a new fit test on the employee’s replacementequipment. An employee might determine that the


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facepiece does not establish an effective facepiece-to-face seal, for example, upon smelling a worksitecontaminant while wearing the respirator with newcartridges. Or an employee might hear or feel airleaking around the facepiece-to-face seal. Theemployee’s determination also can be based onfactors unrelated to the particular worksite. Forexample, the employee might find that he or shecannot wear the respirator for extended periodswithout experiencing irritation or pain.

Employers must ensure that all fit testing con-ducted for employees required to wear tight-fittingfacepiece respirators follows the OSHA approvedprotocols. Detailed protocols for qualitative andquantitative fit testing are provided as part of thestandard (see Appendices A and B of the standard).These protocols specify that you must have onhand during fit testing all types and sizes of respira-tors that are available for use at the worksite. Thisallows you to ensure that each employee is testedwith the same type of respirator (make, model, style,and size) that he or she will wear at the worksite.

Tight-Fitting and Loose-fitting RespiratorFacepiecesA tight-fitting facepiece is intended to form a com-plete seal with the respirator wearer’s face. Thisseal must be sufficiently tight to prevent any con-taminants in the work environment from leakingaround the edges of the facepiece into the user’sbreathing air.

In contrast, a loose-fitting facepiece is specifical-ly designed to form a partial seal with the user’sface. Such a facepiece typically covers at least thehead and includes a system through which cleanair is distributed into the breathing zone. For exam-ple, hoods and helmets are loose-fitting facepieces.Such equipment does not rely on a tight facepiece-to-face seal to protect the wearer, and is useful foremployees with facial hair or other physical charac-teristics that make it difficult to wear a tight-fittingfacepiece.

Preventing Leaks in the Facepiece SealFacepiece seals and valves are important in tight-fitting respirators. Tight-fitting respirators have acomplete seal to the face. If there is a leak in theseal of a tight-fitting respirator or valve, then therespirator cannot reduce the wearer’s exposures torespiratory hazards. You must be sure that nothinginterferes with the seal of the respirator to theemployee’s face or with the valves. Conditions thatcan interfere with the seal or valve include:

• Facial hair

• Facial scars• Jewelry or headgear • Missing dentures• Corrective glasses or goggles or other PPE

such as:•• Face shields•• Protective clothing•• Helmets •• Eyeglass insert or spectacle kits

Employees may use the equipment in the abovelist with tight-fitting respirators if the employerensures that the equipment is worn in a way that:

• Does not interfere with the face-to-facepieceseal.

• Does not distort the employee’s vision.• Does not cause physical harm to the employee

(e.g., if the eyeglass insert did not fit properlyso that the tight fit of the respirator caused theinsert to press against his or her forehead,eyes, or temples).

If an employee wears corrective glasses or gog-gles or other personal protective equipment, theemployer shall ensure that such equipment is wornin a manner that does not interfere with the seal ofthe facepiece to the face of the user.

Conducting User Seal ChecksTo conduct a user seal check, the employee per-forms a negative or positive pressure fit check.

For the negative pressure check, the employee:

• Covers the respirator inlets (cartridges, canis-ters, or seals)

• Gently inhales, and• Holds breath for 10 seconds.

The facepiece should collapse on the employ-ee’s face and remain collapsed.

For the positive pressure check, the employee:

• Covers the respirator exhalation valve(s); and• Gently exhales.

The facepiece should hold the positive pressurefor a few seconds. During this time, the employeeshould not hear or feel the air leaking out of theface-to-facepiece seal. Appendix B-1 of the OSHARespiratory Protection standard provides detailedinstructions on how to conduct the user seal check.The manufacturer’s recommended procedures forchecking the facepiece seal may be used if theemployer demonstrates that the manufacturer’sprocedures are as effective as those described inAppendix B-1 of the OSHA Respiratory Protectionstandard.

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Maintenance and Care of RespiratorsEmployers must provide respirator users withequipment that is clean, sanitary, and in good work-ing order. To accomplish this, employers must havea system of respirator care and maintenance as acomponent of their respiratory protection program.Regular care and maintenance is important toensure that the equipment functions as designedand protects the user from the threat of illness ordeath.

Your system of respirator care and maintenancemust provide for:

• Cleaning and disinfection procedures• Proper storage• Regular inspections• Repair methods

Cleaning and DisinfectionRespirator equipment must be regularly cleanedand disinfected according to specified procedures(see Appendix B-2 of the standard) or according tomanufacturer specifications that are of equivalenteffectiveness.

Cleaning and disinfection procedures are divid-ed into the following:

• Disassembly of components• Cleaning and disinfecting• Rinsing, drying, and reassembly• Inspection

The frequency of cleaning and disinfecting orsanitizing respirators will depend in part onwhether your employees share the equipment orare issued respirators for their exclusive use.Worksite conditions also will dictate cleaning fre-quency, e.g., working in a dirty environment. Inaddition, if individual employees are required toclean their own respirators, you must allow timeduring work hours for users to perform this func-tion.

Proper Storage Procedures for RespiratorsEmployers must store respirators in a manner that:

• Protects them from contamination, dust, sun-light, extreme temperatures, excessive mois-ture, damaging chemicals, or other destructiveconditions.

• Prevents the facepiece or valves from becom-ing deformed.

• Follows all storage precautions issued by therespirator manufacturer.

In addition, if a respirator is intended for emer-gency use, it must be:

• Kept accessible to the work area, but not in anarea that may itself become involved in anemergency and become contaminated or inac-cessible.

• Stored in a compartment or cover (e.g., on afire truck) that is clearly identified as containingemergency equipment.

Training and InformationEmployee training is a critical part of a successfulrespiratory protection program and is essential forcorrect respirator use. Employers must providetraining to their employees who are required towear respirators and must ensure that each employ-ee can demonstrate knowledge of at least the fol-lowing:

1. Why the respirator is necessary and howimproper fit, usage, and maintenance can makethe respirator ineffective.Training must address the identification of haz-ards, the extent of employee exposure to thosehazards, and the potential health effects of expo-sure. The training that is required under theHazard Communication standard (29 CFR1910.1200) can satisfy this requirement forchemical hazards. Employees must understandthat proper fit, usage, and maintenance of respi-rators is critical to ensure that they can performtheir protective function.

2. The limitations and capabilities of the selectedrespirator.Training must cover how the respirator operates.Included must be an explanation of how the res-pirator provides protection by filtering the air,absorbing the gas or vapor, or by supplying aclean source of air. Limitations on the use of theequipment, such as prohibitions against usingan air-purifying respirator in an immediatelydangerous to life and health atmosphere, andwhy not, must also be explained.

3. How to inspect, put on and remove, and checkthe seals of the respirator.Employers must train employees how to recog-nize problems that may decrease the effective-ness of the respirator and what steps to follow ifa problem is detected, such as the person towhom problems should be reported and wherereplacement equipment can be obtained if need-ed. If specialized personnel conduct inspections,individual respirator wearers only need to betaught about the portions of the inspection


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process that are their responsibility. Trainingmust also cover how to properly put on andremove the respirator to ensure that respiratorfit in the workplace is as close as possible to thefit obtained during fit testing.

4. The proper respirator maintenance and storageprocedures.The extent of training required may vary accord-ing to workplace conditions. If employees areindividually responsible for storing and main-taining respirators, detailed training may be nec-essary. If specialized personnel perform thesefunctions, employees only need to be informedof the maintenance and storage procedures.

5. The general requirements of the RespiratoryProtection standard.Employers must ensure that employees areaware, in general, of the employer’s obligationsunder the standard. This discussion need notfocus on the standard’s provisions but could, forexample, simply inform employees that employ-ers are obligated to develop a written program,properly select respirators, evaluate respiratoruse, correct deficiencies in respirator use, con-duct medical evaluations, provide for the main-tenance, storage and cleaning of respirators,and retain and provide access to specificrecords.

Employers must ensure that, before an employ-ee is required to use a respirator in the workplace,he or she understands the information providedand can use the respirator properly. This can be

done by reviewing the training with the employeeeither orally or in writing, and by reviewing theemployee’s hands-on use of respirators. Trainingmust be conducted in a manner that is understand-able to the employees. This means that your pro-gram should be tailored to your employees’ educa-tion level and language background. Employersmust provide the required training prior to requir-ing an employee to use a respirator in the work-place.

If employers can demonstrate that a new employ-ee has received training within the last 12 monthsand that the new employee has the necessaryknowledge, employers are not required to repeatthis training. In cases where training in some ele-ments is lacking or inadequate, employers arerequired to provide training in those elements.Previous training not repeated initially must be pro-vided no later than 12 months from the date of theprevious training.

RetrainingEmployers must retrain employees in the properuse of respirators annually. They must also retrainemployees when:

• Changes in the workplace or the type of respi-rator make previous training obsolete.

• The knowledge and skill necessary to use therespirator properly has not been retained bythe employee.

• Any other situation arises in which retrainingappears necessary to ensure safe respiratoruse.

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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 ServiceReproduced with permission

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 ServiceDHMC, 2005

Developed by Kathy Kirkland, MD, Hospital Epidemiologist, and the DHMC Readiness Committee

Background: The Readiness Plan for Epidemic Respiratory Infection (ERI) evolved from our initial responseand planning for the prevention and control of Severe Acute Respiratory Syndrome (SARS) which began inthe spring of 2003. During those planning activities it became clear that DHMC needs to maintain a level ofreadiness at all times for a variety of contagious respiratory infections with epidemic potential. Potentialthreats include SARS or a new strain of influenza that becomes pandemic. Many elements of the plan willmake us more prepared to identify and contain other contagious respiratory infections as well, includingpertussis, mycoplasma, and parainfluenza, for example.

The DHMC plan builds on guidelines from state and federal health authorities which recommendaggressive implementation of respiratory hygiene practices and universal administration of influenza vac-cine to healthcare workers and high-risk patients for all healthcare facilities regardless of the presence ofan epidemic.

This document outlines a plan for responding to various levels of threat posed by ERIs, and anapproach to stepping up prevention and control activities as the threat increases. It is based on the premis-es that we should be vigilant at all times for syndromes that may represent contagious respiratory infec-tion, and that we should maintain a group of people prepared to actively respond to changing situations byimplementing appropriate parts of this plan, when indicated.

The document is divided into:

• a matrix that defines parameters that will be the critical determinants of the level of risk at DHMC• a summary of the elements of the baseline state of readiness that should be maintained at all times• a summary of the ways in which our surveillance, prevention and control activities may need to

change at each level of increasing risk to DHMC • an appendix that includes standard operating procedures for the management of patients who have

suspected ERI as outpatients, as inpatients, and for resuscitation of these patients.

This document is intended for use by the DHMC Readiness Committee or an Incident Command teamto determine actions that should be taken to prevent the spread of ERI among our patients, staff, volun-teers, students, and visitors. The intent is that this document will be used in the context of advisory docu-ments and guidance provided by NH DHHS and the CDC. It may be used as a template by other NewHampshire healthcare facilities as they prepare themselves for the threat of epidemic respiratory infection.


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What type of transmis-sion is confirmed?

None or sporadic cases only

Person-to-person transmission



Does not matter



Where are the cases?

Anywhere in the world

Anywhere outside theU.S. and borderingcountries (Canada,Mexico)

In the U.S., Canada or Mexico

In region: NH/VT orclose to borders

At DHMC or DC

At DHMC or DC

At DHMC or DC

Epidemic Respiratory Infection ALERT MATRIX

Six levels of alert corresponding to the type of transmission, the location of the cases, and the presenceand type of cases at DHMC or DC.

Are there cases atDHMC?

No

No

No

Does not matter

Yes, but no nosocomialtransmission

Yes, with nosocomialtransmission, fromknown sources only

Yes, with nosocomialtransmission, sourcesnot clear

Alert Level

Ready

Green

Yellow

Orange

“Controlled Orange”

Orange

Red

The alert level will be determined by the Readiness Committee, using this matrix and data collectedthrough surveillance activities. It can be upgraded (or downgraded) by the committee depending on thenumber of cases, or for other compelling circumstances.

At each level of alert, the Readiness Committee will consider implementing certain actions. As the level ofalert becomes higher, additional actions are added to the actions initiated at the lower level.

Level: READY

Baseline activities to ensure preparedness inthe absence of known active epidemic of ERI in the world

Goals

• To prevent cases of vaccine-preventable conta-gious respiratory infection (e.g., influenza) atDHMC and in the community.

• To promote early detection of initial cases ofcontagious respiratory infection (including, butnot limited to influenza, SARS).

• To prevent nosocomial spread of contagiousrespiratory infections.

• To create systems for real-time data collectionflexible enough to be adapted for use in an epi-demic setting.

Influenza Vaccination

• For patients and the public•• Nursing will carry out standing orders for all

eligible patients to be offered and receiveinfluenza vaccine in all clinics and prior to dis-charge from all inpatient units.

•• DHMC will continue to collaborate with othercommunity health organizations to hold pub-lic clinics to provide influenza vaccine to alleligible community members of any age.

•• Public Affairs, with input from the ReadinessCommittee, will develop educational and pro-motional materials to promote availability anddesirability of influenza vaccine for all.

•• The administering provider of flu vaccine inthe inpatient and outpatient setting will docu-ment administration of influenza vaccine inCIS.

• For staff, volunteers, and students•• Administrative, educational, and clinical lead-

ers will promote maximum participation ofstaff, volunteers, and students in influenzavaccine program.

•• Occupational Medicine will provide multipleopportunities for staff, volunteers, and stu-dents to receive influenza vaccine convenient-ly and efficiently.

•• Occupational Medicine will present regularupdates of physician compliance with flu vac-cine by section for review by Board ofGovernors.

•• DHMC will report flu vaccine rates among

direct care providers on public reporting web-site.

Access Control

• The Security Office will develop a plan and atimeline for implementing a policy that enablesthem to control access to the medical centerthrough the use of mandatory ID badges for allstaff, volunteers, students, vendors, and otherpeople coming to DHMC to work, and a plan tolock down certain entrances and exits, and tomonitor use of others, if necessary.

Surveillance, Screening and Triage

• For patients•• Receptionists will screen all outpatients at the

time of registration at selected DHMC clinics,the ED, and the Dartmouth College HealthService with the following question: Do youhave a new cough that has developed overthe last 10 days?, and will:� Provide patients who have a new cough

with a surgical mask and/or tissues.� Document data at time of screening and

transmit clinic-specific data to InfectionControl each week for review and analysisof trends.

•• Clinical staff at these clinics will:� Evaluate patients who have a new cough or

fever.� Place all patients who have fever and a new

cough on droplet precautions, pending fur-ther evaluation.

•• The admitting office staff will screen allpatients at the time of admission for “feverand cough” and will:� Admit patients with fever and cough to a

private room with droplet precautions.� Document data at time of screening and

transmit inpatient admitting diagnoses toInfection Control daily for review of appro-priate use of precautions for inpatients.

• For staff, volunteers, and students•• Receptionists will screen all staff, volunteers,

or students who present to OccupationalMedicine clinic with the following question:Do you have a new cough that has developedover the last 10 days?, and will:� Provide patients who have a new cough

with a surgical mask and/or tissues.� Document data at time of screening and

transmit clinic-specific data to InfectionControl each week for review and analysisof trends.


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•• Clinical staff in Occupational Medicine clinicwill:� Evaluate patients who have a new cough or

fever.� Place all patients who have fever and a new

cough on droplet precautions, pending fur-ther evaluation.

•• Occupational Medicine staff, clinical and ad-ministrative leaders will advise staff, volun-teers and students who have fever and a newcough not to come to work.

•• Occupational Medicine will: � Screen staff, volunteers, and students who

report pneumonia or respiratory infection toidentify possible clusters of pneumonia orrespiratory infection in healthcare providers

� Report possible clusters to Infection Control.• For visitors, vendors, registrants at conferences

•• Public Affairs will maintain “Ask for a Mask”signs at all entrances, and at all meetingrooms, to encourage all persons enteringDHMC to self-screen (rotating the postersperiodically to maintain impact).

•• Via posters, ask persons who have newcough to wear a surgical mask or use tissuesto cover their mouth and nose when cough-ing, and to use good hand hygiene during thetime they need to be at DHMC.

•• All staff will advise persons who have feverand cough to defer visiting DHMC until theirillness has resolved.

• Monitoring surveillance data•• The Infection Control Unit will monitor nation-

al, regional, and local data related to ERI andreport changing trends to the ReadinessCommittee on a regular basis.

Infection Control/Precautions

• All staff, volunteers, and students will useDroplet Precautions (private room and surgicalmask within 3 feet of patient) for all contactwith any outpatient who has a new cough andfever, until a diagnosis of a non-contagiousrespiratory illness, or an infection requiring ahigher level of precautions, is made.

• All staff, volunteers, and students will useDroplet Precautions (private room and surgicalmask within 3 feet of patient) for all contactwith any patient being admitted to the hospitalwho has a new cough and fever until a diagno-sis of a non-contagious respiratory illness, oran infection requiring a higher level of precau-tions, is made.

• Clinic and inpatient staff will use a visible door-way “precautions sign” system to allow per-sons entering the room to know what type ofprotective equipment is needed.

• Clinic Administrative services andHousekeeping will maintain adequate suppliesat all times of surgical masks, waterless handrub, and tissues throughout public areas, clinicwaiting rooms, and meeting rooms. Clinic andinpatient unit staff will maintain these suppliesin clinical areas.

• The Safety Office will identify key areasthroughout the hospital which need to main-tain core groups of N95 respirator fit-testedpersonnel.•• Each director is responsible for maintaining

the appropriate number of trained and fit-test-ed staff

• The Safety Office will ensure that an adequatenumber of PAPRs are maintained for use bypersonnel who cannot use N95 respirators.

• Engineering will maintain negative pressure-capable rooms on 3 West. •• Nursing will develop plans for moving patients

out of these rooms on 3 West if needed.

Communication/Education

• Public Affairs will develop a sustainable andeffective plan for communication and promo-tion of messages relating to ERI to internal andexternal audiences.

• Public Affairs and Communications will coordi-nate with the Emergency Preparedness Com-mittee to develop an internal communicationplan to allow immediate access to predefinedgroups of people, including “on call” staff, viae-mail, Intranet, paging system, telephone.

• The Center for Continuing Education in theHealth Sciences will develop a sustainable planto orient and educate staff regarding basicreadiness activities at DHMC, and a strategy for“just-in-time” educational activities to providetimely information to providers in the event ofERI.

Additional Preparedness Activities

• The Readiness Committee will meet approxi-mately once a month.

• The Readiness Committee will designate anIncident Command core team including senioradministration, infection control, ACOS, com-munications, nursing, safety, engineering,security, College Health Service with 7-day a

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week availability to respond to a potential out-break of contagious respiratory infection.

• The Infection Control Unit will monitor theHealth Alert Network and other communica-tions from public health officials to reviewchanges in recommendations from NHDHHS/CDC about screening criteria and willcommunicate changes to clinicians via somecombination of e-mail, Intranet, or radiographicor laboratory reporting.

Level: GREEN

Confirmed efficient human-to-human trans-mission of potentially epidemic contagiousrespiratory infection present outside the U.S.and bordering countries (Canada and Mexico)

Summary: At the “GREEN” level, our basic activi-ties remain similar to the “READY” level, exceptthat there may be more focused surveillance andscreening based on specific geographic and epi-demiologic risk factors, and more aggressive formsof isolation may be required for suspected cases.Vigilance of all staff is required to identify potentialcases of ERI remains critical. At the GREEN level,the following additional actions will be consideredfor implementation by the Readiness Committee.

Access Control

• The Readiness Committee will consider theneed to activate the policy on requiring staff,volunteers, students, and vendors to wearidentification while in the medical center.


• “Ask for a Mask” signs will be placed at allentrances, and in all meeting rooms, whichmay be modified to include specific risk factorsfor a specific ERI, to encourage all personsentering DHMC to self-screen.•• Persons who self-identify as at risk for the

designated infection are instructed to don asurgical mask and may be asked to go to adesignated location for clinical evaluation.

• Receptionists in selected areas (which mayexpand) will continue to screen all patients atregistration for new cough, and additionalquestions may be added if appropriate.Receptionists will:•• Provide patients who have a new cough who

have specific risk factors for the targeted

infection with a surgical mask and ask clinicalstaff to place them immediately in a privateexam room.

•• Provide patients who have a new cough butno specific risk factors for the targeted infec-tion with a surgical mask and/or tissues.

• Clinical staff will evaluate:•• Patients who answer “yes” to new cough and

specific risk factors for fever and other symp-toms, using N95 masks, gowns, gloves andeye protection.

•• Patients who answer yes to new cough butdo not have specific risk factors, using dropletprecautions.

• Clinicians who suspect, after initial clinical eval-uation that a patient may have an ERI shouldimmediately consult with the InfectiousDisease Service and the Infection Control Unit,who will involve the state health department asappropriate. (IF A PATIENT IS DETERMINED TOBE A SUSPECT CASE OF ERI, GO TO LEVEL:“CONTROLLED ORANGE”)

• No patient can be admitted or accepted intransfer to DHMC with a suspected diagnosisof the ERI in question, without the approval ofthe Infectious Disease Service.

• Staff, volunteers, and students traveling to des-ignated high risk areas must register withOccupational Medicine upon return and reportany symptoms of fever or cough that occurduring a specified time period. OccupationalMedicine will maintain a list of people undersurveillance for this reason.


• Airborne, droplet, and contact precautions arerequired for all contact with any outpatientwho has screened as a possible ERI case, untilan alternate diagnosis is made.

• Droplet precautions are required for all contactwith any outpatient who has a new cough andfever, but no risk factors for the ERI, until adiagnosis of a non-contagious respiratory ill-ness, or an infection requiring a higher level ofprecautions, is made.

• Any patient who has screened as a possibleERI case and requires admission to DHMC,must be admitted to a negative pressure roomon 3 West, where airborne and contact precau-tions are required for all contact. (IF A PATIENTIS DETERMINED TO BE A SUSPECT CASE OFERI, GO TO LEVEL: “CONTROLLED ORANGE”).


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• At each committee meeting, the ReadinessCommittee will review the need for communi-cation with, or educational programs for staff,volunteers, and students, and the public.

Preparedness

• The Readiness Committee meets once or twicea month, depending on the stability of the situ-ation.

Level: YELLOW

Confirmed human-to-human transmission ofpotentially epidemic contagious respiratoryinfection documented in the U.S. or borderingcountries (Canada or Mexico)

Summary: At the “YELLOW” level, the ERI is closerto home, and may pose a more real threat.Vigilance of all to identify potential cases of ERIremains critical. At the YELLOW alert level, rapidchanges in the epidemiology of disease and thelevel of threat to DHMC may be expected. Themajor change is that the Readiness Committeebecomes more active so that a rapid change to ahigher level of alert is possible. The following addi-tional activities will be considered.

Access Control

• Review need to require staff, volunteers, stu-dents, and vendors to wear ID badges at alltimes.


• Expand screening and triage of patients andemployees to all clinics, with regular review ofneed to modify or add specific risk factors.

• Continued use of posters to promote screeningvisitors and vendors.


• No changes


• No changes

Preparedness

• The Readiness Committee meets at least oncea week to review surveillance data and newrecommendations from DHHS/CDC.

• Evaluate the availability and appropriateness ofdisease-specific vaccine or preventive treat-ment.

Level: CONTROLLED ORANGE

A case of ERI has been diagnosed at DHMC orDartmouth College or is an inpatient atDHMC but there has been no documentednosocomial or community spread from thisperson to others.

Summary: When there is a patient with suspectedERI at DHMC, because of the potential for transmis-sion in the hospital setting, the alert level immedi-ately is raised to a form of ORANGE. (i.e., with asingle imported case, we immediately would gofrom READY or GREEN to CONTROLLED ORANGE.)At the “CONTROLLED ORANGE” level, more cau-tion is needed, and our activities shift from morepassive to more active control measures. The goalis to prevent nosocomial spread to employees andpatients within DHMC. At this level, activation of anumber of new measures is considered, relating toaccess, screening, and clinical care, but there is aneffort to maintain relatively normal operations atDHMC except in the area where a potentially infect-ed patient is being cared for. The emphasis is onpersonal protection of staff and patients, and areadiness to raise the alert level quickly if there isany indication of spread.

Access Control

• Limit visitors and admissions to 3 West.• Review need to restrict vendors, visitors, con-

ferences.• Require staff, volunteers, students, vendors,

and other people coming to DHMC to work towear their badges/identification at all times.


• Modified “Ask for a Mask” signs remain at allentrances, and at all meeting rooms, whichinclude specific risk factors for the targetedinfection, to encourage all persons enteringDHMC to self-screen.•• A knowledgeable staff member may need to

be present at all entrances to assist peoplewith self-screening, answer questions, anddirect them to evaluation centers if needed.

• Screening questions for patients and employ-ees at registration, admission will be reviewedand modified as needed at each ReadinessCommittee meeting.

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• Staff, volunteers, and students who have hadcontact with suspected patients must registerwith Occupational Medicine and be screeneddaily for fever or respiratory symptoms.

• Surveillance data will be transmitted toInfection Control for review daily.


• No changes


• Regular updates to all staff via Intranet asdetermined by the Readiness Committee.

Preparedness

• Readiness Committee will meet daily to reviewsituation and strategies.

• Nursing and ACOS will review plans for mov-ing non-epidemic patients out of negative pres-sure-capable rooms on 3 West; Engineeringwill review plan to add HEPA filters and nega-tive pressure to additional rooms on 3 Westand ensure that the plan could be operational-ized within 4 hours if needed.

• Infection Control will notify microbiology labo-ratory director of relevant information.

Level: ORANGE

There is evidence of nosocomial transmissionof ERI from known infected patients to otherpatients, employees, or visitors at DHMC, ORthere is human-to-human transmission in theUpper Valley region, or nearby.

Summary: “ORANGE” indicates a high level ofalert, with restrictions on access to DHMC, muchmore active screening, and a shift away from nor-mal operations throughout the institution. At theORANGE level, the Readiness Committee will con-sider implementing each of the following additionalactions.

Access Control

• All entrances to medical center will be lockedexcept the Main Entrance, the entrance fromParking Garage, and the EmergencyDepartment entrance.

• Security guards will be stationed at openentrances.

• Entry into facility will be restricted to the fol-lowing:•• Staff, and students with valid ID

•• Patients with appointments•• A single adult accompanying a patient

•• A single parent of hospitalized child• Those allowed into the facility must be

screened for fever or cough (see Surveillance,screening and triage below) and have theirtemperature taken and if cleared, given some-thing to indicate that they have been cleared toenter the facility (e.g., a sticker, a card, a stampon their hand).

• Activities of Food Court eateries and shops,hair salon, optical shop, etc. will be suspended.

• Activities of vendors, volunteer activities, con-tinuing education programs, except thoserelated to the epidemic disease will be sus-pended.

• There will be some degree of suspension ofelective surgeries, elective admissions, electiveoutpatient appointments as determined by theReadiness Committee.

• There will be some level of suspension of med-ical student rotations, construction as deter-mined by the Readiness Committee.


• Patients calling for same day appointments willbe screened for new cough developing overthe last 10 days.•• Patients who answer yes will be phone

triaged to a clinician who can do furtherscreening for epidemic infection risk factorsand determine the need for the patient to beevaluated in person.

• Patients being called with appointmentreminders will be screened for new cough andphone triaged to a clinician for further screen-ing prior to coming to DHMC.

• All people entering DHMC will be activelyscreened by trained staff for cough or fever atopen entrances •• Patients and visitors who are identified to

have fever and/or cough will be instructed todon a surgical mask, use waterless handrub,and go to a designated evaluation location(NB: risk factors at this alert level may be sim-ply living in the Upper Valley, or having beenat DHMC).


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•• Employees who have fever and/or cough willbe considered possible cases: � If at home, they should call Occupational

Medicine for evaluation prior to coming towork.

� If at work, they should call OccupationalMedicine and be instructed regarding theneed for evaluation.

� Occupational Medicine will develop a tool toscreen employees regarding need for evalu-ation, need for home isolation, etc.

•• After evaluation, no patient or employee whohas fever or cough will be allowed to remainat DHMC unless the person requires hospital-ization.� The name and phone number/address of all

patients or employees sent home with sus-pected epidemic infection should be record-ed and reported to the NH DHHS.

• Occupational Medicine will continue to main-tain a log of which employees have contactwith epidemic patients, whether there areunprotected exposures, and the employee’shealth and work status daily.


• An N95 mask and contact precautions arerequired for all HCWs having contact with anyoutpatient who has fever and/or a new cough,until an alternate diagnosis is made. (Thisincludes staff who conduct screening at DHMCentrances.)

• Adequate supplies of personal protectiveequipment, waterless hand rub, tissues willbe maintained throughout the hospital byHousekeeping and Clinic AdministrativeServices, as well as clinical staff.

• Everyone providing patient care will be N95respirator fit-tested.


• Daily or more frequent updates to staff and thepublic/press will be provided as determined bythe Readiness Committee.

Preparedness

• The Readiness Committee will meet twice dailyto review infection control surveillance data,clinic operations (i.e., number of screeningevaluations being done) and adequacy of newcontrols and revise alert level as needed.

• The Readiness Committee will reassess dailythe need to create special epidemic inpatient

unit off site (e.g., Armory).• Staff may be redeployed from areas where

clinical activities have been suspended or limit-ed to screening, infection control, OccupationalMedicine, epidemic patient care and otherareas of need, as determined by ReadinessCommittee in collaboration with hospital lead-ers.

Level: RED

There is evidence of untraceable or uncon-trolled nosocomial transmission of ERI ORthere is widespread human-to-human trans-mission in the Upper Valley region, or nearby

Summary: “RED” indicates the highest level ofalert, with extreme restrictions on access to DHMCand a major shift away from normal operationsthroughout the institution. The following additionalactions will be considered.

Access Control

• All entrances to medical center will be lockedexcept one entrance designated for employeesand Emergency Dept entrance.

• Security guards will be stationed at openentrances.

• Entry into facility will be restricted to the fol-lowing:•• Employee with valid ID

•• Patient arriving by ambulance [a parent mayremain with a hospitalized child but cannotcome and go from the medical center]

•• Patients who must receive regular, life-sus-taining treatments at DHMC (e.g., dialysispatients, transfusion-dependent patients)

• Those allowed into the facility must bescreened for cough and other criteria (as out-lined in ORANGE) and have their temperaturetaken and if cleared, given something to indi-cate that they have been cleared to enter thefacility.

• Suspension of elective surgeries, electiveadmissions, elective outpatient appointments,non-emergency transfers as determined by theReadiness Committee.

• Suspension of on-site student rotations, con-struction activities.•• Possible redeployment of clinical students to

areas of need.

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• Required daily for all persons entering facility(see ORANGE).


• All staff will wear surgical masks and use fre-quent hand hygiene at all times while in thefacility.


• There will be daily or more frequent updates tostaff and the public/press as determined by theReadiness Committee.

Preparedness

• The Readiness Committee will meet twice dailyto review situation.

• The Readiness Committee will reassess dailythe need to create special epidemic inpatientunit off site (e.g., Armory).

• Staff may be redeployed from areas whereclinical activities have been suspended or limit-ed to screening, infection control, OccupationalMedicine, epidemic patient care and otherareas of need, as determined by ReadinessCommittee in collaboration with hospital lead-ers.


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Appendix 1

Epidemic Respiratory Infections Patient Flow

Patient Response to Risk Factor Screening Questions?

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Yes

Proceed with appointment as scheduled.

Receptionist gives surgical mask topatient and notifies nurse.

Nurse places pt in room, door closed, implements airborne/contact

precautions with N95 masks.

Evaluation by scheduled providerConfirms symptoms & risk factors

Initial disposition

No

ID Consult - confirm symptoms & riskfactors, review disposition, discusswith Infection Control & NH DHHS

Suspect Case?

YesNo

Continue with scheduled appt

Does patient need to be admitted?

No

Complete evaluationin clinicYesNot sure

ED for Evaluation

Admission to NegativePressure Room

Home

ICU 3W

The following protocol will be followed when apatient has a new cough and risk factors associatedwith a specific epidemic respiratory infection (ERI).

Principles to follow in care of ERI patient.

• Minimize Health Care Workers (HCW) contactwith the patient.

• Protect HCWs during contact with patient.• Minimize opportunities for exposure to other

patients or visitors.

Key points

1. The receptionist should give the patient a maskto put on covering their nose and mouth and imme-diately inform the nurse who will immediately placethe patient in a private exam room, the door to theexam room must be kept closed. We want to mini-mize the amount of time that the patient is in thewaiting area or other common areas.

2. Personnel Protective Equipment (PPE) is requiredfor anyone going in the room to see the patient.This includes gown, gloves, goggles and N95 maskor PAPR hood. N95 masks and the PAPR hoods willbe available from the Safety Office (ext. 57233) dur-ing the day or the ACOS after hours.

3. The health care provider who was scheduled tosee the patient will evaluate them to confirm thatthey have a fever >38, respiratory symptoms andrisk factors for ERI. If the provider confirms thisinformation s/he should contact the InfectiousDisease physician by calling the DHMC operatorand asking for the ID physician on call.

4. The ID physician will consult with the patient’sprovider to confirm the suspect case and plan fur-ther evaluation. They will also notify the InfectionControl Team and the NH Department of Health. Ifpossible, a disposition decision should be made atthis time.

5. If the patient is in a clinic without a negativepressure room and is considered to be a suspectcase of ERI and needs further evaluation, including

lab work and/or X-rays, to determine the need forhospital admission they will be moved as soon aspossible to the negative air pressure room in theEmergency Department. The clinic nurse caring forthe patient must call the ED (ext 57000) and notifythem of this. When the patient is moved to the ED,they should be wearing a surgical mask. Thepatient should be taken to the ED via a route thatavoids crowded public areas. The clinic nurse whohas been caring for the patient will transport thepatient to the ED and should continue to wear PPE.

If the patient is no longer considered to be asuspect case they may continue with their appoint-ment as scheduled. People no longer need to fol-low contact and airborne isolation, only appropriateStandard Precautions.

6. The patient will remain in the negative pressureroom in the ED until a decision regarding admis-sion is made. The patient will only leave for urgentmedically necessary tests that can not be done inthe negative pressure room. If the patient needs toleave the ED, the charge nurse is responsible fornotifying the department that they will be going tothat the patient requires airborne and contact pre-cautions. The PPE will go with the patient whenthey leave the ED. Employees who have contactwith the patient should be kept to a minimum.

7. If the patient is stable and does not need admis-sion the provider should coordinate appropriatemedical follow-up and surveillance from the NHDepartment of Health prior to discharge from theclinic or ED.

8. If the patient requires admission to DHMC theInfectious Disease physician will activate the ERIplan and notify Admitting of the need to admit thepatient to a negative pressure room. N95 masksand PAPR hoods will be sent with the patient. Thepatient will travel from the clinic or ED to the unitwearing a surgical mask via a route that avoidscrowded public areas. The nurse who has been car-ing for the patient will transport the patient to theinpatient room and should continue to wear PPEduring transport.


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Appendix 2

Suspected or Confirmed Epidemic Respiratory Infection (ERI) Outpatient Management Protocol

This plan will be put into effect when a patient isbelieved to meet the criteria for an epidemic respi-ratory infection by one of the Infectious Diseasephysicians and needs hospitalization.

Principles to follow in care of ERI patient

• Minimize Health Care Workers (HCW) contactwith the patient.

• Protect HCWs during contact with patient.• Minimize opportunities for exposure to other

patients or visitors.

Criteria for Admission

• Patient will be admitted only when medicallynecessary.

• Patients will not be admitted solely for the pur-pose of isolation.

• The Infectious Disease service must approve alladmissions for ERI and is responsible for acti-vating the ERI plan in collaboration withInfection Control.

Admitting Service/Medical ResponsibilityThe ERI patient will be admitted to the Hospitalistservice, adult or pediatric, with mandatory consulta-tion with Infectious Disease and Critical Care Serviceon admission. Transfer to the Critical Care Serviceshould be made as soon as a patient shows signs ofrespiratory distress, i.e., increasing O2 requirement,FI02 > 50, respiratory therapy assessment.

Patient Placement All patients, adult and pediatric, will be admitted to3W. The first case will be admitted to room 301. (Ifthe first patient is critically ill, requiring immediateintensive care they should be admitted to a nega-tive pressure room in the ICU for an adult or thePICU for a child.)

• Planning and activity will begin to prepareroom 303 as a potential intensive care location.Engineering will install special ventilation unitto create negative pressure (EngineeringServices Policy 6.207b; Temporary NegativePressure Rooms).

Second case will be admitted to room 302.

• 3W- Pod 1 now restricted to only ERI patients.ACOS, Admitting, and nursing directors will

make arrangements to move the non-ERIpatients on Pod 1 to another area of the hospi-tal.

• Engineering will install special ventilation unitsto create negative pressure in rooms 327, 328,and 329. Contact State of NH to get moreportable HEPA filter units.

• Plan for provision of adequate staff initiated.This may require cancellation of elective casesand re-allocation of nursing staff.

ERI patients 3, 4, & 5 will be admitted to rooms 327,328, & 329.

• When these rooms are full, 3W will be closedto all other patient types.

• Non-ERI patients will be moved to other areasof the hospital.

• Plans initiated to open an alternate site for careof ERI patients outside of MHMH.

• ERI patients will continue to be admitted to3West until alternate care site is opened. Otherunits of the hospital may need to accept patients(non ERI) from 3W. Other areas of the hospitalmay need to close some beds in order to pro-vide extra staff to 3W.

Any patient requiring critical care support will beplaced in Room 303. Nursing staff from ICU willprovide critical care in this location.

Pediatric patients will be admitted to the roomson 3West (not the Pedi/Adolescent unit). Nursingstaff from the Pedi/Adolescent unit will provide careto the pediatric patient on 3West.

If the number of ERI patients exceeds the num-ber of available private negative pressure roomspatients with known ERI can be cohorted together.The following patients will be given priority for theprivate negative pressure rooms; these decisionswill be made in collaboration with the ACOS,Infectious Disease, Infection Control, and Admitting.

• ERI patients who are known to have transmit-ted ERI to others.

• Patients who are being assessed for ERI (donot want to put someone who does not ulti-mately have ERI in with known ERI patients).

As soon as the Admissions Department is awareof ERI patient admission they will notify the ACOS(ext 5-8245 or beeper # 9732) of the admission.

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Appendix 3

Suspected or Confirmed Epidemic Respiratory Infections (ERI) Inpatient Management Protocol

The ACOS will work with Admitting and the 3Wstaff to expedite the admission. (The patient willremain where s/he has been evaluated until theinpatient room is ready.) The ACOS will:

• Expedite transferring current patient to anotherroom

• Notify engineering of the admission, engineer-ing will ensure negative pressure is functioningin the room (This can be done by holding asmall strip of tissue paper at the closed doorand observing to be sure that it is pulledtoward the room, not blown out away from theroom. Engineering can assist with this if need-ed.)

• Ensure the room’s pressure monitor alarm hasbeen turned on and is working. Use the key toturn the room pressure monitor to “InfectiousIsolation - Negative Pressure”. This only turnsthe room alarm on, the room is always on neg-ative pressure and does not need to be turnedon. The alarm should go on when the door isleft open for more than 1 minute or the seal isnot adequate to maintain negative pressure inthe room. Before the patient arrives to theroom, check the room pressure monitor to besure it is working by opening door, the alarmshould go off after 1 minute. If there are ques-tions about the monitor or room call Engineer-ing. Monday through Friday 0800-1600 Ext. 5-7150. At other times use Engineering Pager#9234.

• Ensure unnecessary equipment (extra chairs,cot) is removed from the room

• Ensure that protective equipment is availablein the anteroom (masks, gowns, goggles,gloves, PAPR units); Masks and goggles can beobtained from Stores, gowns from LinenService ext. 57136, and PAPR units are in theEmergency Department. If rooms without ananteroom are used for a ERI patient the neces-sary equipment will need to be set up on a cartoutside the room.

Patient TransportGuidelines for moving ERI patients in DHMC

• The nurse caring for the patient will transportthe patient with the assistance of transporta-tion personnel as needed.

• If an elevator is needed, use a service elevatorand be sure there are no other people in it.

• The patient must wear a surgical mask overtheir nose and mouth during transport throughthe institution.

• Security (ext. 5-7896) can help with providingan empty elevator available and other logisticsif needed.

• Employees who are transporting the patientshould wear gloves, N95 mask (or PAPR hoodand motor unit), goggles, and gown.

Protective EquipmentAnyone entering the room must wear respiratoryprotection appropriate to the disease. If the diseaseis transmitted via the airborne route then the fol-lowing is required.

• N95 mask (employee must have been fittedand trained by an administrator of theRespiratory Protection Program) and goggles(face shields are not felt to provide adequateprotection).

• If the employee cannot be fitted for an N95mask they must wear a PAPR unit when enter-ing the room. (People wearing a PAPR hood donot need goggles; the hood provides protec-tion for the eyes.)

• Everyone must wear gloves and a gown.

When leaving the room the PPE will be removedin the anteroom, if there is one, or just outside thedoor if the room does not have an anteroom.Remove PPE in the following order.

• Untie the gown’s waist tie • Remove gloves and dispose of them in trash • Remove goggles handling them by the side

pieces and place in sink• Remove mask handling it by the head straps

and dispose of in trash• Untie neck ties of gown and carefully remove

gown turning sleeves inside out as arms arepulled out, place gown in linen bag

• Put new gloves on and disinfect goggles withalcohol or Dimension III

• Remove gloves and dispose• WASH HANDS before doing anything else.

People who have used a PAPR unit shouldremove PPE in the following order:

• Remove hood and motor unit and place onchux pad

• Remove gloves, dispose of them in trash andput new gloves on, clean hood, hose andmotor with Dimension III, place unit in cleanarea and dispose of chux pad

• Untie the gown’s waist tie• Remove gloves and dispose of them in trash• Untie neck ties of gown and carefully remove

gown turning sleeves inside out as arms are


7 9

pulled out, place gown in linen bag. • WASH HANDS before doing anything else.

All of the PPE, except for the PAPR units, areeither disposable or single use and should not bereused.

N95 masks will not be reused. They will be dis-posed in the trash of as soon as they are removed.

PAPR units must be disinfected as soon as theyare removed. The person who used the equipmentis responsible for cleaning it and plugging in themotor unit to recharge while it is not in use. Thehood and hose must be wiped with a disinfectantbefore being handled and used again. The motorunit should be wiped with a disinfectant if it hasbeen in contact with respiratory secretions.

Room SetupBoth doors to rooms 301 and 302 must be keptclosed. When other rooms are used, the single doorto the room must be kept closed.

Only essential equipment should be in the room.Equipment brought into the room should be left inthe room for use only by that patient. Thermometer,stethoscope glucometer, pulse oyx, should remainin the room. A thermometer can be obtained fromCSR, a glucometer can be obtained from Point ofCare Testing, ext 57198, in the lab, pulse oyx can beobtained from respiratory therapy. Equipment thatcannot be left in the room must be disinfectedbefore it is used for any other patient. Most equip-ment can be disinfected by cleaning thoroughlywith Dimension III.

Linen requires no special precautions. Usedlinen should be handled as little as possible. Itshould be carefully rolled together in a manner thatavoids shaking, and placed in the yellow linen bags.

Trash requires no special precautions. Routinewaste should be placed in the regular trash bags.Any waste that is saturated with blood or body flu-ids should be disposed of in the tan bags.

Regular dishes will be used. The dietary aide willgive the tray to the nurse who will bring it into theroom. The nurse will also bring the tray out of theroom when the meal is finished.

Blood and other specimens may be sent to thelab via normal mechanisms. Be sure the outside ofthe biohazard bag does not become contaminated.

The patient room should be cleaned daily and asneeded by housekeeping. While the patient is in theroom the housekeeping staff must wear N95 maskand goggles or a PAPR unit and gloves and gownswhile in the room. Routine cleaning with a disinfec-tant is adequate. When the patient is dischargedthe room should be left closed for an hour, then

people may enter without masks to clean.

StaffingNursing staff from Pediatrics and the Critical Careunits will provide care to pediatric or critical carepatients on 3W.

The registered nurse taking care of a ERIpatient will not care for any other patients. Otherstaff members such as LNAs who may be neededto assist with care may care for other patients.

The goal is to limit the number of employeeswho enter the room while providing appropriatesafe care for the patient.

All employees will be expected to participate inthe care of ERI patients as needed.

Pregnant employees will not be excused fromcaring for ERI patients.

Staff who are taking care of ERI patients maywear hospital supplied scrub uniforms. (There is acabinet in Stores that has a few scrubs available foremergency use, a larger supply will need to beordered from the linen department.)

Staff who have cared for a ERI patient mayshower in their locker room before leaving work.

Employee SurveillanceA list of all employees who enter the room or havehad close contact with the patient will be started byInfection Control as soon as the ERI plan is activat-ed and maintained by the RN who is assigned tothe patient. All employees entering the room orwho have contact with the ERI patient must addtheir name and contact information to the list. Theunit secretary will FAX the prior day’s list toOccupational Medicine (FAX 650-0928) between8:00 and 9:00 a.m. each day. These employees willbe followed by Occupational Medicine for symp-toms of the disease. Occupation Medicine willdevelop a disease-specific protocol for close moni-toring of all employees who have had contact withthe ERI patient.

VisitorsNo visitors. People can talk to the patient via tele-phone.

For pediatric patients, one parent may beallowed in the room. They will need to use PPE andfollow policies as above. They may not sleep in theroom.

Special SituationsCough inducing or aerosol producing procedures(intubation, sputum induction, nebulizer treatment,CPAP, BiPAP, suctioning) should not be done unless

8 0


absolutely necessary. If they must be done thepatient should be medicated if possible to limitaerosol production (sedate, paralyze). The absoluteminimum number of employees should be in theroom. Employees who are in the room during sucha procedure must wear PAPR units.

To the extent possible all tests and procedureswill be done in the patient’s room. Medically neces-sary tests that cannot be done in the patient’s roomneed to be planned and coordinated with thedepartment doing the test so that the patient doesnot wait in the department’s waiting area, as fewstaff as possible are present and they have appro-priate PPE, as few other patients as possible are inthe area. The room and equipment must be appro-priately cleaned after the patient leaves and beforeanother patient is seen.

If surgery is needed it should be done at a timewhen as few other patients as possible are in theOR. The patient should be brought directly into theOR, not wait in the holding area. As few staff aspossible should be in the room. The OR staff in theroom should all wear N95 masks and goggles aswell as other appropriate PPE.

If the patient needs dialysis, this will be done inthe patient’s room. The patient will not go to thedialysis unit.

In the event of cardiopulmonary arrest aProtected Code Blue will be called. Only 6 mem-bers of the code team will be in the room. Theymust all wear the appropriate PPE; PAPR unit,gloves and gown. Equipment and supplies must goin only one direction (equipment and supplies thatare taken off the code cart are not put back on thecart).

Cohorting of Patients and StaffIf there is significant ERI transmission in the facilityor frequent unprotected exposures then patientsand staff may need to be cohorted in separateareas of the facility according to their exposure sta-tus;

• No exposure• Unprotected exposure but no symptoms• Unprotected exposure with symptoms but do

not meet the ERI case definition• Symptoms meet the ERI case definition


8 1

This policy has been reviewed and accepted by

Hospitalist Service

Critical Care Service

Pediatric Service

Infectious Disease Service

Occupational Medicine Department

Emergency Department

GIM Clinic

Admitting Department

ACOS

Nursing Director for 3W

Nursing Director for Pediatrics

Nursing Director for Critical Care

Housekeeping Department

Engineering

Perioperative Services

CPR Committee

Respiratory Therapy

Security

Transportation

Laboratory

Risk Management

Appendix D-1 Sample Self-Triage Algorithm for Persons with Influenza SymptomsReproduced with permission from the Department of Veterans Affairs, VA Pandemic Influenza PlanAppendix E-5: SAMPLE Self-Triage Algorithm for Persons with Influenza Symptoms.

You may have influenza (flu).When should you seek additional help from a healthcare provider?

The symptoms of influenza are: • Fever—low (99˚F) to high (104˚F), usually for 3 days, but may persist for 4 to 8 days. Sometimes fever

will go away and return a day later. • Aching muscles • Cough • Headache • Joint aches • Eye pain • Feeling very cold or having shaking chills • Feeling very tired • Sore throat, runny or stuffy nose

8 2

Appendix D Self-Triage and Home Care Resources for HealthcareWorkers and Patients

If you have some of these symptoms:

Stay Home• Rest• Drink Fluids• Take fever reducers (acetaminophen or ibupro-

fen)

But IF you

• Are unable to drink enough fluids (urinebecomes dark; you may feel dizzy whenstanding)

• Have fever for more than 3 to 5 days• Feel better, than develop a fever again

Or IF you

• Become short of breath or you developwheezing

• Cough up blood• Have pain in your chest with breathing• Have heart disease (like angina, or con-

gestive heart failure) and you developchest pain

• Become unable to walk or sit up, orfunction normally (others might be theones to notice this-especially in elderlypersons)

CALL your healthcare provider GO RIGHT AWAY for healthcare

Appendix D-2 Home Care Guide for InfluenzaReproduced with permission from the Department of Veterans Affairs, VA Pandemic Influenza Plan AppendixE-6, Home Care Guide for Influenza: Symptom and Care Log, Infection Control Measures for the Home.

A person with influenza will often become ill very suddenly. Fever and the worst symptoms often last threedays, but sometimes last as many as eight days. The person may feel weak, tired, or less energetic thannormal for weeks afterward, and may have a long-lasting hacking cough.

Common symptoms: Fever—low (99˚F) to high (104˚F), usually for 3 days, but may persist for 4 to 8 days. Sometimes fever willgo away and return a day later.

• Extreme fatigue • Muscle and body aches • Feeling very cold or having shaking chills • Joint aches • Headache (may be severe) • Eye pain • Sore throat • Stuffed nose or runny nose • Dry cough initially, may become a deep, hacking, and painful cough over the course of several days • No appetite for food or desire to drink fluids

Supplies to have on hand: • Thermometer • Acetaminophen• Cough suppressants/cough syrup • Drinks—fruit juices, sports drinks• Light foods—clear soups, crackers, applesauce• Blankets; warm covers

Caring for a person with influenza:• Comfort measures

•• Have the patient rest in bed.•• Allow the sick person to judge the amount of bed covers needed; when fever is high the person may

feel very cold and want several blankets.

•• Give acetaminophen or ibuprofen according to the package label or a health care provider’s directionto reduce fever, headache, and muscle, joint or eye pain.

• Fluids—give frequently, extremely important to replace body fluids that are lost as a result of fever.• Feeding

•• Give light foods as the person wants: fluids are more important than food, especially in the first dayswhen the fever may be highest.

When to seek additional medical advice:• If the person is short of breath or breathing rapidly at rest• If the person’s skin is dusky or bluish in color • If the person is disoriented (“out of it”) • If the person is so dizzy or weak that standing is difficult (in a person who was able to walk before the

illness)• If the person has not urinated in 12 or more hours


8 3

Symptom and Care Log for Home Care(Copy, fill out, and bring log sheets to healthcare provider visits)

Name of patientName of healthcare provider

Date Time Observations* Temperature Medication

8 4

* How the person looks; what the person is doing; fluids or foods taken since the last observation.

Appendix E-1. Influenza Diagnostic Table


8 5

Appendix E References for Diagnosis and Treatment of Staff During an Influenza PandemicPlease refer to www.pandemicflu.gov or http://www.pandemicflu.gov/vaccine/#testing for current informa-tion and recommendations. Reproduced from the CDC Influenza (Flu) Laboratory Diagnostic Procedures forInfluenza webpage, http://www.cdc.gov/flu/professionals/labdiagnosis.htm. Last accessed March 6, 2007.

Procedure

Viral culture

Immunofluorescence DFAAntibody Staining

RT-PCR5

Serology

Enzyme Immuno Assay(EIA)

Rapid Diagnostic Tests

Directigen Flu A7

(Becton-Dickinson)

Directigen Flu A+B7,9

(Becton-Dickinson)

Directigen EZ Flu A+B7,9

(Becton-Dickinson)

FLU OIA4,7 (Biostar)

FLU OIA A/B 7, 9

(Biostar)

XPECT Flu A&B7,9

(Remel)

NOW Influenza A8,9

(Binax)

NOW Influenza B8,9

(Binax)

NOW Influenza A&B8,9

(Binax)

OSOM® Influenza A&B9

(Genzyme)

QuickVue Influenza Test4,8

(Quidel)

InfluenzaTypes

Detected

A and B

A and B

A and B

A and B

A and B

A

A and B

A and B

A and B

A and B

A and B

A

B

A and B

A and B

A and B

Acceptable Specimens

NP swab2, throat swab, nasal wash,bronchial wash, nasal aspirate, sputum

NP swab2, nasal wash, bronchial wash,nasal aspirate, sputum

NP swab2, throat swab, nasal wash,bronchial wash, nasal aspirate, sputum

paired acute and convalescent serumsamples6

NP swab2, throat swab, nasal wash,bronchial wash

NP wash and aspirate

NP swab2,aspirate, wash; lower nasalswab; throat swab; bronchioalveolarlavage

NP swab2, aspirate, wash; lower nasalswab; throat swab; bronchioalveolarlavage

NP swab2, throat swab, nasal aspirate,sputum

NP swab2, throat swab, nasal aspirate,sputum

Nasal wash, NP swab2, throat swab

Nasal wash/aspirate, NP swab2



Nasal swab

NP swab2, nasal wash, nasal aspirate

Time forResults

3-10 days 3

2-4 hours

2-4 hours

>2 weeks

2 hours

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes

Rapid result

available

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

8 6


QuickVue Influenza A+BTest8,9

(Quidel)

SAS Influenza A Test7,8,9

SAS Influenza B Test7,8,9

ZstatFlu4,8

(ZymeTx)

A and B

A

B

A and B

NP swab2, nasal wash, nasal aspirate

NP wash2, NP aspirate2

NP wash2, NP aspirate2

throat swab

<30 minutes

<30 minutes

<30 minutes

<30 minutes

Yes

Yes

Yes

Yes

1. List may not include all test kits approved by the U.S. Food and Drug Administration.

2. NP = nasopharyngeal.

3. Shell vial culture, if available, may reduce time for results to 2 days.

4. Does not distinguish between influenza A and B virus infections.

5. RT-PCR = reverse transcriptase polymerase chain reaction.

6. A fourfold or greater rise in antibody titer from the acute- (collected within the 1st week of illness) to the convalescent-phase (collected 2-4 weeks after the acute sample) sample is indicative of recent infection.

7. Moderately complex test – requires specific laboratory certification.

8. CLIA-waived test. Can be used in any office setting. Requires a certificate of waiver or higher laboratory. certification.

9. Distinguishes between influenza A and B virus infections.

Disclaimer: Use of trade names or commercial sources is for identification only and does not imply endorse-ment by the Centers for Disease Control and Prevention or the Department of Health and Human Services.

1. Hospital Preparedness Checklist (Department of Health and Human Services) http://www.hhs.gov/pandemicflu/plan/sup3.html#app2

2. Long-term Care and Other Residential Facilities Pandemic Influenza Planning Checklist (Department of Health and Human Services)http://www.pandemicflu.gov/plan/LongTermCareChecklist.html

3. Medical Offices and Clinics Pandemic Influenza Planning Checklist (Department of Health and Human Services)http://www.pandemicflu.gov/plan/medical.html

4. Emergency Medical Services and Non-emergent (Medical) Transportation Organizations Pandemic Influenza Planning Checklist (Department of Health and Human Services)http://www.pandemicflu.gov/plan/emgncy medical.html

5. Home Health Care Services Pandemic Influenza Planning Checklist (Department of Health and Human Services)http://www.pandemicflu.gov/plan/healthcare.html

6. Department of Veterans Affairs (VA) VA Pandemic Influenza Plan Appendix D-2: Sample Emergency Management Program Standard Operating Procedure (SOP)http://www.publichealth.va.gov/flu/pandemicflu_plan.htm#


8 7

Appendix F Pandemic Planning Checklists and Example Plans

Appendix F-1 Sample Emergency Management ProgramStandard Operating Procedure (SOP)Reproduced with permission from the Departmentof Veterans Affairs Pandemic Plan, Appendix D-2:Sample Emergency Management ProgramStandard Operating Procedure (SOP).

Pandemic Influenza Affecting A VA HealthcareFacility (Modify for your facility)

Emergency Management Program GuidebookDepartment of Veterans Affairs

THE DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER (LOCATION)

EMERGENCY MANAGEMENT PROGRAM (DATE) STANDARD OPERATING PROCEDURE NO. ( )

SUBJECT: VA Health Care Facility’s Preparation andResponse to an Influenza Pandemic

Description of the Threat/Event. a.Agent. A pandemic occurs when a new strain

of influenza virus emerges that has the abilityto infect and be passed between humans.Because humans would have little immunity tothe new virus, a worldwide epidemic, or pan-demic, can ensue. Influenza viruses havethreatened the health of human populationsfor centuries. The diversity and propensity ofinfluenza viruses for mutation have thwartedefforts to develop both a universal vaccine andhighly effective antiviral drugs. As a result, anddespite annual vaccination programs and mod-ern medical technology, even seasonal influen-za in the United States results in approximately36,000 deaths and 226,000 hospitalizationseach year. A pandemic strain of influenza couldcause manyfold more. Transmission of influen-za is aided by the fact that infected people mayshed virus and spread the infection for one-halfday to one day before symptoms begin.

b.Clinical Disease. Symptoms of influenza typi-cally begin two days after exposure, oftenstarting with a sudden onset of fever, severefatigue or muscle pain, sore throat, and a drycough. Uncomplicated seasonal influenza com-monly leads to three to five days of acute ill-ness, including fever and prostration, leavingthe sufferer feeling weakened and with a resid-ual cough for two or more weeks longer. A

new strain may present a different clinicalcourse and be much more serious, causingsevere morbidity and mortality from influenzapneumonia or pneumonitis and secondarybacterial infections.

c. Public Health Response. Public health meas-ures to slow or stop a pandemic influenzawill likely include a number of actions thatwill have a range of success. A monovalentinfluenza vaccine made for the specific pan-demic strain will be manufactured, but this willtake several months. An antiviral medication,oseltamivir, that can be given to exposed per-sons to prevent illness and help limit transmis-sion is available but supplies are limited andmanufacturing is a complex process.Oseltamivir may be effective against the H5N1avian influenza that has infected humans inAsia and Europe; VA holds a 500,000 treatmentcourse stockpile of oseltamivir. Other publichealth measures include commonsenseactions, like hand washing, respiratoryhygiene, staying home when sick, and usingtelework or telecommuting options when able.Health care facility actions involve isolating thesick, having staff wear appropriate personalprotective equipment (PPE), and screening forinfluenza illness or exposure before permittingentry to a facility. Community, regional, andnationally-mandated measures may includedeclaration of “snow days”, postponing oflarge public gatherings, quarantine of theexposed, and restrictions on travel.

Impact on Mission Critical Systems. • An influenza pandemic can quickly overwhelm

a VA medical center’s or community-based out-patient clinic’s normal capacity to provide time-ly and accessible medical care. Because of theease with which influenza is transmitted,healthcare facilities can quickly become sites ofintensive exposure for staff and non-infectedpatients. Breaks in procedure or unanticipatedexposures may overwhelm a whole MedicalCenter, for example, by exposing personneland requiring quarantine of the Medical Center.For this reason it is incumbent that VHA facili-ties prepare for the possibility of an influenzapandemic.

• An influenza pandemic can quickly overwhelma hospital’s or CBOC’s mission critical systems,causing such problems as:

• Staffing shortages from community quarantineand competing family interests.

8 8


• Depleted supplies of vaccines and antivirals. • Stretched bed capacity and operational space

required for patient care or quarantine. • A pandemic, by definition, will be a wide-

spread—even national—event, so close coordi-nation and cooperation with local, county, statepublic health agencies; and private sectorhealthcare facilities will be necessary and vital.It will also be necessary for VA medical centersto anticipate VA’s mission to back up theDepartment of Defense (and provide care todesignated members of the military) and VA’sresponsibilities to the National Response Plan(and provide care and resources for care tonon-enrolled veterans and non-veterans).

Operating Units and Key Personnel withResponsibility to Manage this Threat.• Facility Director – Responsible for assuring

the organization implements the necessarypreparatory measures for a potential influenzapandemic. The Director is also responsible forinitiating the organization’s disaster plan.

• Infection Control Team/Epidemiology – Key rolein: tracking potential and confirmed cases;infection control management of patients usingairborne precautions (private room, negativeairflow, N95 respirator use by staff) or, whenthe Medical Center is overwhelmed, usingdroplet precautions and cohorting (isolation ofinfectious patients together, but away fromnon-exposed); working with and reporting tolocal and state public health agencies; servingas a VA medical center information resourceon changing public health recommendationsand on the community/outbreak; assisting withvaccination decisions affecting staff andpatients; and advising on mass distributionsystems for vaccine and antivirals.

• Engineering Service – Key role in: assessmentof negative airflow rooms and negative airflowsystems; identification of areas suitable forcohorting patients both in waiting areas andafter hospitalization.

• Clinical Laboratory – Key role in: obtaining andperforming diagnostic tests for the pandemicstrain; knowing availability of reference labora-tories for diagnosis (like the CDC’s LaboratoryResponse Network [LRN] or state laboratories);advising on specimen collection; safe handling,storage, and shipping of specimens.

• Safety/Industrial Hygiene – Key role in: supportof N95 respirator usage (fit testing) program.

• Police and Security – Key role in: crowd con-trol, managing the flow of patients and visitors.If the situation warrants, police have key role inperimeter control, site access. Police may becalled upon to protect the supply of influenzavaccines and supplies like oseltamivir, vaccine,N95 masks, and surgical or procedure-typemasks. Perimeter access and site control maypertain to staff, staff relatives/family, andpatients and require ingress and egress con-trol. Site control may include assisting withdrive-through triage stations or drive-throughclinic sites, and mass distribution of vaccineand antivirals.

• Medical Service – Key role in: clinical diagnosisof cases; treatment of cases; providing health-care advice via telephone; staffing innovativecare delivery sites, advising/assisting withmass delivery of vaccine and antivirals.

• Nursing Service – Key roles in: staffing and bedsupport for inpatient, outpatient, and innova-tive care delivery sites; assisting with restric-tion of non-essential personnel from patientrooms (i.e., environmental management serv-ice, nutrition and food service personnel); pro-viding healthcare advice via telephone; advis-ing/assisting with mass delivery of vaccine andantivirals.

• Emergency Department – Key role in: monitor-ing incoming patients suspected of exposureor disease; making decisions on maintainingseparate clinical activities.

• Pharmacy – Key role in managing the supply ofvaccines and antivirals.

• Employee/Occupational Health – Key role in:employee vaccination/clinical care (identifica-tion of vaccine contraindications), informationflow/risk communication to staff; advising/assisting with advice to staff about their abilityto work, maintaining healthcare records forstaff, including immune status.

• EMS/Safety – Key role in: advising on cleaningof rooms; equipment; communication of adviceon cleaning measures.

• Volunteer Service – Key role in: coordinatingvolunteers (existing and community members)willing to assist. Volunteers also should assistin establishing an area for child care andrespite for healthcare facility staff unable toleave the facility.

• Public Affairs – Key role in: keeping staff andpatients informed, updating website, workingwith VSOs, media.


8 9

Mitigation/Preparedness Activities of theThreat/Event. The mode(s) of transmission, degree of morbidi-ty and mortality, and amount of societal disrup-tion that a pandemic influenza might cause willbe uncertain until the specific influenza strain isidentified and observed. From applying what is known about seasonal influenza, it might beexpected that a pandemic influenza would followsome of the same transmission patterns: readytransmission by respiratory droplets (and per-haps by aerosolized particles) from person toperson; shedding and transmission of virusbefore persons are ill, a short incubation periodof approximately 2 days, and thus a potentialdoubling of cases every 2 to 3 days.

a. Hazard Reduction.•• Notification/risk communications plan.

•• Activation of hospital emergency plan. •• Perimeter control potential: need for

increased security staffing, heightened securi-ty requirements for access control.

•• Building systems assessment for cohortingpotential and confirmed patients.

•• Implementation of measures to provideadded capacity for a potential surge of inpa-tient and ambulatory care.

•• Exposure control/Infection control: AirborneInfection Isolation and Contact Precautionsare advised for a potentially lethal strain ofpandemic influenza, in order to maximallyprotect staff. Patients should be placed inroom with negative airflow and HEPAexhaust; and should wear surgical maskswhen transported through the Medical Center.If facilities are unable to exercise this degreeof isolation, cohorting of patients in common,exposed areas with HVAC isolation and exhaust(if possible) and use of respiratory dropletprecautions by staff are advised.

•• Separation of new, unexposed patients frompotential pandemic influenza cases.

•• Use of Airborne Infection Isolation andContact Precautions, if possible, or DropletPrecautions.

•• Visitor restriction policies.

•• If necessary, control of the perimeter: need forincreased security staffing, heightened securi-ty requirements for access control.

b. Preparedness Strategies and Resources.•• Establishment of Pandemic Response Team

that will be prepared to work during a pan-demic.

•• Vaccination (if available). •• Antiviral medications prescribed to prevent

illness in the exposed or unvaccinated (ifavailable).

•• Public health measures of hand washing,respiratory hygiene, staying home when ill,respecting quarantine, isolation, “snow day”and travel, and public gathering limitations.

•• Education (on public health measures, infec-tion control guidelines, home care, self-triage[to determine when medical care is neces-sary]).

•• Plan for Airborne Infection Isolation andContact Precautions for all personnel withpatient contact.

•• Anticipation of need to manage a large num-ber of fatalities.

Response/Recovery from the Event/Threat. a. Hazard Control and Monitoring Strategies.

•• First case identified at a VAMC. 1. Should be immediately reported: any

suspected case(s) of pandemic influenzato Infection Control for confirmation.Infection Control would then brief theChief of Medicine and the Chief of Staff.If case is confirmed, the Director, SafetyOfficer, Police and Occupational Healthwould be notified (this will most likelyoccur when a known pandemic virus iscirculating elsewhere in the world and aVA medical center suspects it has the firstU.S. or regional case).

2. Activate Infection Control Team for initia-tion of patient/exposed staff tracking sys-tem, patient/staff educational informa-tion.

3. Clear all patients and employees fromthe vicinity of the suspected case.

4. Document details of incident and namesof all persons within the immediate “atrisk” area (i.e., who have become con-tacts and may require quarantine, antivi-ral medications).

5. Contact local/state public health contactsfor diagnostic sample collection andshipping instructions.

9 0


6. Contact local/state public health agen-cies, Pharmacy Benefits Management, orVACO Office of Public Health andEnvironmental Hazards to obtain vaccine,depending on guidance provided at thetime (if pandemic vaccine is available).

7. Contact Pharmacy Benefits Management,or VACO Office of Public Health andEnvironmental Hazards for access to VA’soseltamivir (antiviral medication) stock-pile.

8. Activate Infection Control Team for initia-tion of patient/exposed employee track-ing system, patient/employee educationalinformation.

9. Initiate antiviral medication for all poten-tial exposed persons as appropriate afterdiscussion with local/state public healthagencies, if appropriate.

10. Notify internal personnel, as appropriate,including Chief of Staff, Health CareProviders, Nursing Service, Pharmacy,Microbiology Laboratory, and Engineeringfor immediate inventory of criticalresources.

11. Immediately assess potential impact ofactual event on mission-critical systemsto include staffing, critical supplies, oper-ational space, potential for patient andstaff exposures and HVAC system.

•• Cases already identified among existingenrolled veterans. 1. VA personnel must maintain communica-

tions and awareness with local and statepublic health agencies of progression ofthe pandemic in the community. Infor-mation must be shared with internal VApersonnel, including VAMC Director,Chief of Staff, Police and Security, ChiefNurse Executive, Safety Officer/IndustrialHygienist, Employee/OccupationalHealth, Emergency Room Personnel,Health Care Providers, Pharmacy, andMicrobiology Laboratory for immediateinventory of critical resources. A. Perform active surveillance for pan-

demic influenza appearing amonghospitalized inpatients, or outpatientsaccording to the prevailing case defi-nition.

B. Notify the Clinical MicrobiologyLaboratory of potential for use ofrapid diagnostic tests or sending ofspecimens to reference laboratories.

C. Immediately assess potential impact ofreported community events on mis-sion critical systems to includestaffing, critical supplies and opera-tional space.

D. Await follow-up information from localauthorities and prepare for potentialpresentation of patients.

b. Resource Issues. •• Staffing needs will be monitored and ad-

dressed by Chief of Staff, Chief of Nursing,VAMC Director, and other involved ServiceChiefs.

•• Critical Supplies – Vaccine (if available at thetime) will likely be distributed through statehealth departments or through VA CentralOffice Pharmacy Benefits ManagementStrategic Healthcare Group. Additional timelyinformation about vaccine may be expectedfrom VACO. Other critical supplies to assessin the event of pandemic influenza includerespiratory support equipment (oxygen, andoxygen-delivery equipment, ventilators), per-sonal protective equipment, antimicrobialsoap and alcohol-based hand cleaners, antibi-otics to treat secondary bacterial pneumonias,morgue kits.

•• Resource Allocation – Develop criteria andtransparent processes for allocation decisionsregarding resources that may not be availablein sufficient quantities during a pandemic:antivirals, respirators, vaccines, staff.

•• Space Management – Assess negative airflowroom and cohorting bed and space availabili-ty; refrigerated space to store bodies.

•• Emergency Room capabilities, acute care clin-ic capabilities and current/projected bed avail-ability should be immediately assessed.

•• Exposed patients and staff might expectshort-term quarantine on site or relocation toalternate care sites or alternate healthcarefacilities.

•• Consideration should be given to providingpandemic influenza countermeasures that arein short supply to staff members’ families(vaccine, antivirals, personal protective equip-ment), depending on availability and on thefacility’s responsibilities and assignmentsunder the National Response Plan. If staffmembers’ families can be protected, staff willbe more available to take care of patients.


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c. Clinical Response.•• Treatment protocols will be based upon pre-

vailing knowledge of the pandemic influenzastrain and will include supportive care (respi-ratory support, hemodynamic support) anduse of antivirals.

•• Clinical admission/treatment decisions will bemade by the health care providers.

•• All quarantine and visitor restriction decisionswill be made by the VAMC Director basedupon recommendations of the InfectionControl Team or pandemic influenza responseteam following local/state public health guid-ance and decisions, and advice of regional VAcounsel, if needed. Such decisions will beproportional to the disease impact, necessary,relevant, and applied equitably, and willemploy the least restrictive means if optionsare available.

•• All patients treated and evaluated for poten-tial pandemic influenza must be reported tothe Infection Control Team or designated pan-demic influenza response team for data col-lection.

•• Patient and staff recordkeeping must bemaintained according to usual standards, ifpossible.

•• The Infection Control Team or designatedpandemic influenza response team will moni-tor all potential cases and make appropriatereports to the VAMC Director and state andlocal public health agencies.

Notes:1.Vaccination of Health Care Providers: Vaccine

for a pandemic influenza strain will be devel-oped once the strain is known. This vaccinewill most likely be distributed to states andthen to public and private medical centers.Changes and updates on vaccine availabilitywill be communicated to VISNs and VAMCsfrom VACO.

i. The Infection Control Team, or desig-nated pandemic influenza responseteam, working with the Chief of Staffand VAMC Director will notify HealthCare Providers when treatment/expo-sure guidelines are updated or as newresources are made available. TheInfection Control Team can monitorthe VA pandemic influenza websites

for these updates. Note that VA guid-ance may differ from CDC guidance.

d. Recovery Strategies.•• Periodic critical supply inventories with re-

supply or supplementation from outside facili-ties, as needed.

•• Periodic staffing census with workload redis-tribution, as needed.

•• Close monitoring of patient census and bedstatus.

•• Monitoring of staff and patient mental health.

External Notification Procedures. a. Within VA. VISN, VACO. b. Other State and Federal Agencies. Local and

state public health departments who will notifyCDC. •• OSHA – follow prevailing rules for notification

of employee fatalities and hospitalizations. c. Community Entities. Neighboring hospitals,

emergency response systems (police, firefight-ers, emergency medical services, 911 opera-tors).

Specialized Staff Training. • Health Care Provider Training – Recognition of

clinical syndromes associated with influenza,treatment protocols, guidelines for personalprotective equipment.

• Infection Control Team Training – Passive andactive surveillance systems for monitoringreportable infectious disease pathogens.

• Safety Specialist/Industrial Hygienist – N95 res-pirator usage.

• Clinical Laboratories – Diagnostic tests, speci-men collection, handling, and shipping.

• Social Work Service – Introductory training onpandemic influenza, risks, treatments, familyimplications, and follow-up.

• Police and Security – Introductory training onpandemic influenza, PPE recommendations.

• Environmental Management Service Personnel– Introductory training on pandemic influenzarisks, decontamination of environments, bed-clothing management, PPE recommendations.

References and Further Assistance. • The VA Pandemic Influenza Plan. • The VA Respiratory Infectious Diseases

Emergency Plan (an amendment to the VHAEmergency Management Guidebook).

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• Federal websites on pandemic influenzawww.pandemicflu.gov

• Phone Numbers. •• VACO Office of Public Health and

Environmental Hazards - 202-273-8575, 8567

•• VACO Pharmacy Benefits Management - 708-786-7886

Review Date(NAME) Chief, (SERVICE NAME) Attachment:

Key Activity Management Tool/Structure

Available at http://www.publichealth.va.go/watch/respiratoryID.htm

• VHA Under Secretary for Health InfluenzaAdvisories. Available at http://www.publichealth.va.gov/flu/advisory.htm

• Local, County, State Health Departments (24/7contact information must be part of your emer-gency plans for pandemic influenza).

• VA guidance and websites on pandemicinfluenza www.publichealth.va.gov/infectiondontpassitonhttp://www.publichealth.va.gov/flu/pandemicflu.htm

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1. Department of Health and Human Serviceshttp://www.pandemicflu.gov/rcommunication/

“Message maps” are risk communication tools used to convey complex information, and to make iteasier to understand. Each primary message has three supporting messages that can be used to pro-vide context for the subject of the primary message.

http://www.pandemicflu.gov/rcommunication/ pre_event_maps.pdf

2. Association of State and Territorial Health Officialshttp://www.astho.org/?template=risk_ communication.html

3. Substance Abuse and Mental Health Services Administrationhttp://www.riskcommunication.samhsa.gov/ index.htm

4. World Health Organizationhttp://www.who.int/csr/resources/publications/ WHO_CDS_2005_31/en/http://www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdfhttp://www.who.int/csr/don/Handbook_ influenza_pandemic_dec05.pdf

Appendix G Risk Communication Resources

Appendix G-1 Risk and Crisis Communication: 77 Questions Commonly Asked byJournalists During a Crisis (Reproduced with permission from: Covello, V.T.,“Risk Communication and Message Mapping: ANew Tool for Communicating Effectively in PublicHealth Emergencies and Disasters,” Journal ofEmergency Management, Vol.#4 No.#3, 25-40(2006)).

Journalists are likely to ask six questions in a crisis(who, what, where, when, why, how) that relate tothree broad topics: (1) What happened?; (2) Whatcaused it to happen?; (3) What does it mean?

Specific questions include:

1. What is your name and title?2. What are your job responsibilities?3. What are your qualifications?4. Can you tell us what happened?5. When did it happen?6. Where did it happen?7. Who was harmed?8. How many people were harmed?9. Are those that were harmed getting help?10. How certain are you about this information?11. How are those who were harmed getting help?12. Is the situation under control?13. How certain are you that the situation is under

control?14. Is there any immediate danger?15. What is being done in response to what hap-

pened?16. Who is in charge?17. What can we expect next?18. What are you advising people to do?19. How long will it be before the situation returns

to normal?20. What help has been requested or offered from

others?21. What responses have you received?22. Can you be specific about the types of harm

that occurred?23. What are the names of those who were

harmed?24. Can we talk to them?25. How much damage occurred?26. What other damage may have occurred?27. How certain are you about damages?28. How much damage do you expect?29. What are you doing now?30. Who else is involved in the response?31. Why did this happen?32. What was the cause?33. Did you have any forewarning that this might

happen?

34. Why wasn’t this prevented from happening?35. What else could go wrong?36. If you are not sure of the cause, what is your

best guess?37. Who caused this to happen?38. Who is to blame?39. Could this have been avoided?40. Do you think those involved handled the situa-

tion well enough?41. When did your response to this begin?42. When were you notified that something had

happened?43. Who is conducting the investigation?44. What are you going to do after the investiga-

tion?45. What have you found out so far?46. Why was more not done to prevent this from

happening?47. What is your personal opinion?48. What are you telling your own family?49. Are all those involved in agreement?50. Are people overreacting?51. Which laws are applicable?52. Has anyone broken the law?53. How certain are you that mistakes have not

been made?54. Have you told us everything you know?55. What are you telling us?56. What effects will this have on the people

involved?57. What precautionary measures were taken?58. Do you accept responsibility for what hap-

pened?59. Has this ever happened before?60. Can this happen elsewhere?61. What is the worst case scenario?62. What lessons were learned?63. Were those lessons implemented? Are they

being implemented now?64. What can be done to prevent this from hap-

pening again?65. What would you like to say to those who have

been harmed and to their families?66. Is there any continuing danger?67. Are people out of danger? Are people safe? 68. Will there be inconvenience to employees or to

the public?69. How much will all this cost?70. Are you able and willing to pay the costs?71. Who else will pay the costs?72. When will we find out more?73. What steps need to be taken to avoid a similar

event?74. Have these steps already been taken?75. If not, why not?76. Why should we trust you?77. What does this all mean?


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Appendix H-1 Examples of Consumable and DurableSupply NeedsReproduced and modified from the HHS PandemicInfluenza Plan Supplement 3 Health Care Planning,Box 2.

• Consumable resources •• Hand hygiene supplies (antimicrobial soap

and alcohol-based, waterless hand hygieneproducts)

•• Disposable N95 respirators, surgical and pro-cedure masks

•• Face shields (disposable or reusable) •• Gowns •• Gloves •• Facial tissues •• Central line kits •• Morgue packs

• Durable resources •• Ventilators •• Respiratory care equipment •• Beds •• IV pumps

http://www.hhs.gov/pandemicflu/plan/sup3.html

Appendix H-2 Suggested Inventory of Durable andConsumable Supplies for VeteransAdministration Health Care Facilities during a Pandemic InfluenzaReproduced with permission from Department ofVeterans Affairs, VA Pandemic Plan

Durable resources

• Mechanical ventilators • Manual resuscitators (bag-valve mask) • Beds • Stretchers/gurneys • IV pumps • Positive air purifying respirators (PAPRs) or

other equivalent respirators

Consumable resources (consider stockpiling a 4-week supply)

• Hand hygiene supplies (antimicrobial soap andalcohol-based [>60%], waterless hand hygienegels or foams)

• Disposable fit-testable N95 respirators

• Elastomeric respirators with P100 filters • Surgical and procedure-type masks • Goggles • Gowns • Gloves • Facial tissues• Central line kit• Morgue packs • IV equipment • Syringes and needles for vaccine administra-

tion• Respiratory care equipment

•• Portable oxygen •• Regulators and flow meters•• Oxygen and ventilator tubing, cannulae,

masks•• Endotracheal tubes, various sizes •• Suction kits •• Tracheotomy•• Vacuum gauges for suction and portable suc-

tion machines• Intensive care unit (ICU) monitoring equipment

Medications (consider stockpiling a 4-week supply)

• Nonsteroidal anti-inflammatory drugs(NSAIDs), pill and liquid forms

• Acetaminophen (pill, suppository, liquid) • Antibiotics (consider ciprofloxacin, levofloxacin

po and iv, vancomycin, piperacillin/tazobactam,ceftriaxone)

• Antivirals (oseltamivir) • Vaccines (pandemic and seasonal influenza,

pneumococcal)• Vasopressors• Benzodiazepines, propofal • Proton pump inhibitors• Bronchodilators

Items to consider including in home care kits

• Thermometers • NSAIDs or acetaminophen • Cough suppressants • Oral rehydration mix packs • Surgical or procedure-type masks for the

patient to wear around others and for careproviders to wear around the patient

• Printed home care instructions, including VAfacility contact information and informationabout symptoms that should prompt thepatient to see a healthcare provider

Appendix H Sample Supply Checklists For Pandemic Planning


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OSHA Assistance

OSHA can provide extensive help through a variety ofprograms, including technical assistance about effec-tive safety and health programs, state plans, work-place consultations, and training and education.

Safety and Health Program Management System GuidelinesEffective management of worker safety and healthprotection is a decisive factor in reducing the extentand severity of work-related injuries and illnesses andtheir related costs. In fact, an effective safety andhealth management system forms the basis of goodworker protection, can save time and money, increaseproductivity and reduce employee injuries, illnesses and related workers’ compensationcosts.

To assist employers and workers in developingeffective safety and health management system,OSHA published recommended Safety and HealthProgram Management Guidelines (54 Federal Register(16): 3904-3916, January 26, 1989). These voluntaryguidelines can be applied to all places of employmentcovered by OSHA.

The guidelines identify four general elements criti-cal to the development of a successful safety andhealth management system:• Management leadership and worker involvement,• Worksite analysis,• Hazard prevention and control, and• Safety and health training.

The guidelines recommend specific actions, undereach of these general elements, to achieve an effectivesafety and health management system. The FederalRegister notice is available online at www.osha.gov.

State ProgramsThe Occupational Safety and Health Act of 1970 (OSHAct) encourages states to develop and operate theirown job safety and health plans. OSHA approves andmonitors these plans. Twenty-four states, Puerto Ricoand the Virgin Islands currently operate approvedstate plans: 22 cover both private and public (state andlocal government) employment; Connecticut, NewJersey, New York and the Virgin Islands cover thepublic sector only. States and territories with theirown OSHA-approved occupational safety and healthplans must adopt standards identical to, or at least aseffective as, the Federal OSHA standards.

Consultation ServicesConsultation assistance is available on request toemployers who want help in establishing and main-

taining a safe and healthful workplace. Largely fundedby OSHA, the service is provided at no cost to theemployer. Primarily developed for smaller employerswith more hazardous operations, the consultationservice is delivered by state governments employingprofessional safety and health consultants.Comprehensive assistance includes an appraisal of allmechanical systems, work practices, and occupationalsafety and health hazards of the workplace and allaspects of the employer’s present job safety andhealth program. In addition, the service offers assis-tance to employers in developing and implementingan effective safety and health program. No penaltiesare proposed or citations issued for hazards identifiedby the consultant. OSHA provides consultation assis-tance to the employer with the assurance that his orher name and firm and any information about theworkplace will not be routinely reported to OSHAenforcement staff. For more information concerningconsultation assistance, see OSHA’s website atwww.osha.gov.

Strategic Partnership ProgramOSHA’s Strategic Partnership Program helps encour-age, assist and recognize the efforts of partners toeliminate serious workplace hazards and achieve ahigh level of worker safety and health. Most strategicpartnerships seek to have a broad impact by buildingcooperative relationships with groups of employersand workers. These partnerships are voluntary rela-tionships between OSHA, employers, worker repre-sentatives, and others (e.g., trade unions, trade andprofessional associations, universities, and other gov-ernment agencies).

For more information on this and other agencyprograms, contact your nearest OSHA office, or visitOSHA’s website at www.osha.gov.

OSHA Training and EducationOSHA area offices offer a variety of information serv-ices, such as technical advice, publications, audiovisu-al aids and speakers for special engagements. OSHA’sTraining Institute in Arlington Heights, IL, providesbasic and advanced courses in safety and health forFederal and state compliance officers, state consult-ants, Federal agency personnel, and private sectoremployers, workers and their representatives.

The OSHA Training Institute also has establishedOSHA Training Institute Education Centers to addressthe increased demand for its courses from the privatesector and from other federal agencies. These centersare colleges, universities, and nonprofit organizationsthat have been selected after a competition for partici-pation in the program.

OSHA also provides funds to nonprofit organiza-tions, through grants, to conduct workplace trainingand education in subjects where OSHA believes there

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is a lack of workplace training. Grants are awardedannually.

For more information on grants, training and edu-cation, contact the OSHA Training Institute, Directorateof Training and Education, 2020 South ArlingtonHeights Road, Arlington Heights, IL 60005, (847) 297-4810, or see Training on OSHA’s website atwww.osha.gov. For further information on any OSHAprogram, contact your nearest OSHA regional officelisted at the end of this publication.

Information Available ElectronicallyOSHA has a variety of materials and tools available onits website at www.osha.gov. These include electronictools, such as Safety and Health Topics, eTools, ExpertAdvisors; regulations, directives and publications;videos and other information for employers and work-ers. OSHA’s software programs and eTools walk youthrough challenging safety and health issues andcommon problems to find the best solutions for yourworkplace.

OSHA PublicationsOSHA has an extensive publications program. For alisting of free items, visit OSHA’s website at

www.osha.gov or contact the OSHA PublicationsOffice, U.S. Department of Labor, 200 ConstitutionAvenue, NW, N-3101, Washington, DC 20210; tele-phone (202) 693-1888 or fax to (202) 693-2498.

Contacting OSHATo report an emergency, file a complaint, or seekOSHA advice, assistance, or products, call (800) 321-OSHA or contact your nearest OSHA Regional or Areaoffice listed at the end of this publication. The tele-typewriter (TTY) number is (877) 889-5627.

Written correspondence can be mailed to the near-est OSHA Regional or Area Office listed at the end ofthis publication or to OSHA’s national office at: U.S.Department of Labor, Occupational Safety and HealthAdministration, 200 Constitution Avenue, N.W.,Washington, DC 20210.

By visiting OSHA’s website at www.osha.gov, youcan also:• File a complaint online,• Submit general inquiries about workplace safety

and health electronically, and• Find more information about OSHA and occupa-

tional safety and health.

(OOC 5/2009)


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OSHA Regional Offices

Region I(CT,* ME, MA, NH, RI, VT*) JFK Federal Building, Room E340Boston, MA 02203(617) 565-9860

Region II(NJ,* NY,* PR,* VI*)201 Varick Street, Room 670New York, NY 10014(212) 337-2378

Region III(DE, DC, MD,* PA, VA,* WV)The Curtis Center170 S. Independence Mall WestSuite 740 WestPhiladelphia, PA 19106-3309(215) 861-4900

Region IV (AL, FL, GA, KY,* MS, NC,* SC,* TN*)61 Forsyth Street, SW, Room 6T50Atlanta, GA 30303(404) 562-2300

Region V(IL, IN,* MI,* MN,* OH, WI)230 South Dearborn Street Room 3244Chicago, IL 60604(312) 353-2220

Region VI(AR, LA, NM,* OK, TX)525 Griffin Street, Room 602Dallas, TX 75202(972) 850-4145

Region VII(IA,* KS, MO, NE)Two Pershing Square2300 Main Street, Suite 1010Kansas City, MO 64108(816) 283-8745

Region VIII(CO, MT, ND, SD, UT,* WY*)1999 Broadway, Suite 1690PO Box 46550Denver, CO 80202-5716(720) 264-6550

Region IX (American Samoa, AZ,* CA,* HI,* NV,* Northern Mariana Islands)90 7th Street, Suite 18-100San Francisco, CA 94103(415) 625-2547

Region X(AK,* ID, OR,* WA*)1111 Third Avenue, Suite 715Seattle, WA 98101-3212(206) 553-5930

*These states and territories operate their ownOSHA-approved job safety and health programsand cover state and local government employeesas well as private sector employees. TheConnecticut, New Jersey, New York and VirginIslands plans cover public employees only. Stateswith approved programs must have standards thatare identical to, or at least as effective as, theFederal OSHA standards.

Note: To get contact information for OSHA AreaOffices, OSHA-approved State Plans and OSHAConsultation Projects, please visit us online atwww.osha.gov or call us at 1-800-321-OSHA.

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pandemic influenza preparedness and response guidance

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department of health

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hazardspecific safety

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