Guidance: Infection Prevention and Control Measures for Occupational Health Management for all Health Care Settings

Human Cases of Pandemic (H1N1) 2009 Flu Virus

Posted: 2009-12-15

This guidance document has been developed to provide guidance for the occupational health (OH) and infection prevention and control (IPC) management of health care workers¹ (HCWs) and other staff to prevent the transmission of Pandemic (H1N1) 2009 Flu Virus in all settings where health care is provided. While it is expected that this document will provide helpful information to all HCWs, its primary audience is those individuals who are responsible for IPC and OH in all settings where health care is delivered. This guidance will cover prevention strategies, occupational exposures, post-exposure management and treatment of ill HCWs as well as recommend definitions of fitness-for-work.

This guidance document is being provided by the Public Health Agency of Canada (PHAC) in response to the Pandemic (H1N1) 2009 Flu Virus outbreak.  This guidance is based on current, available scientific evidence about this emerging disease, and is subject to review and change as new information becomes available.  The following guidance should be read in conjunction with relevant provincial and territorial guidance documents and existing federal/provincial/territorial legislations and regulations.  PHAC will be posting regular updates and related documents at www.phac-aspc.gc.ca.  The content of this document has been informed by discussion with and technical advice provided by the Infection Control Expert Advisory Group to PHAC.

 

The clinical picture to date in Canada, of human illness from Pandemic (H1N1) 2009 Flu Virus is one of mild disease for most individuals, however, some individuals will experience moderate or severe disease.  At this time, the epidemiologic data from PHAC suggests that the incubation period for H1N1 2009 is on average  4 days and untreated individuals may remain infectious for up to 7 days, or longer if severely ill or immunocompromised. With the exception of a few case reports of resistance to oseltamivir, Pandemic (H1N1) 2009 Flu Virus is susceptible to the antiviral agents oseltamivir and zanamivir, which represent therapeutic options.  Full application of PHAC’s infection prevention and control guidelines, Routine Practices and Additional Precautions, including Pandemic Influenza Precautions measures will minimize or prevent the transmission of all infection, including pandemic influenza in settings where health care is provided.

Spread of Pandemic (H1N1) 2009 Flu Virus has been almost exclusively in the community setting to this point, and this is where most exposures for the general public and health care workers alike will likely occur. When HCWs and other staff are in the larger community (e.g. out shopping, attending public gatherings) they will share the same risk of acquiring influenza as the general population.

This guidance may require modification as the clinical and epidemiological picture changes.

For occupational health management, the following criteria for influenza-like-illness (ILI) can be used to determine the need for applying the occupational health and infection prevention and control measures found in this guidance:

• Acute onset of respiratory illness with cough and/or fever*
• And 1 or more of: sore throat, headache, arthralgia, myalgia, or prostration (refer to Appendix A)

*Although surveillance criteria specify fever and cough, fever is not always present with Pandemic (H1N1) 2009 Flu Virus infection. The recommended criteria in this guidance document are more stringent than PHAC surveillance criteria, in order to minimize the risk of introducing influenza into the healthcare setting by an infected HCW or other staff member.

This guidance document is to be used in conjunction with other existing H1N1 guidance documents.

The following are occupational health and infection prevention and control measures for Pandemic (H1N1) 2009 Flu Virus.

1. Organizational Occupational Health Planning
2. Education
3. Influenza Immunization
4. HCW and Staff Self-assessment
5. Hand Hygiene
6. Respiratory Hygiene (also known as Respiratory Cough Etiquette)
7. Fitness-for-work specific to Pandemic (H1N1) 2009 Flu Virus
8. Definition of Occupational Exposure specific to Pandemic (H1N1) 2009 Flu Virus
9. Antiviral Treatment specific to Pandemic (H1N1) 2009 Flu Virus 
10. Reporting

1. Organizational Occupational Health Planning

An effective OH program will include a hierarchy of system and personal control measures, (i.e., engineering and administrative controls, use of vaccine and personal protective equipment (PPE)), to enable employees of healthcare organizations to perform their duties in an environment that minimizes their risk of exposure to hazards, including infectious agents.  It is recommended that healthcare organizations do the following: 

1. Implement a HCW immunization program for seasonal and Pandemic (H1N1) 2009 Flu Virus influenza vaccine.
2. Ensure that HCWs and other staff have access to equipment and training to perform their work activities safely.
3. Provide a Respiratory Protection Program that provides individual risk assessment, fit testing and education, including education in seal checks for HCWs or other staff who are required to use respirators.
4. Provide pandemic influenza education and skills training for HCWs and other staff, including importance of influenza immunization (see 3. below) and instruction in HCW safety aspects of a point-of-care risk assessment (see 2. below).
5. Reduce exposure to pandemic influenza for HCWs, and other staff, at risk for severe complications from influenza by development and administration of fitness-for-work policies (see 7. below).
6. Develop methods to identify, track, report and manage clusters of ILI affecting HCWs and other staff and communicate any occurrence of clusters to those responsible for IPC and/or OH within the organization.
7. Ensure compliance with applicable federal/ provincial/ territorial legislations and regulations.

2. Education

It is recommended that all healthcare organizations, including agencies that supply contract workers to healthcare settings provide appropriate education and skills training for all HCWs and other staff regarding prevention and control of pandemic influenza in healthcare settings. Important components of education and training include a review of the organization’s pandemic influenza occupational health and hygiene and infection prevention and control plan, the importance of influenza immunization (see 3. below), point-of-care risk assessment, consistent application of Routine Practices (including hand hygiene and respiratory hygiene) and Additional Precautions, including the Pandemic Influenza Precautions that are intended to prevent exposure to and transmission of pandemic influenza during the provision of health care.  In addition, it is recommended all HCWs be instructed in how to perform self-assessment for symptoms of influenza (see 4. below), and on recommendations regarding fitness-for-work (see 7. below).

3. Influenza Immunization

It is recommended that HCWs and other staff receive annual influenza immunization for seasonal influenza.  In addition, it is recommended that HCWs and other staff receive the Pandemic (H1N1) 2009 Flu Virus vaccine. 
It is recommended that vaccinated individuals be advised to continue a daily self-assessment for ILI (see Appendix A).

As per Routine Practices, it is also recommended that HCWs and other staff (vaccinated or recovered from H1N1) be advised to continue to use infection prevention measures such as hand hygiene, cough etiquette and PPE to protect against new strains of influenza virus and other infectious respiratory agents.

4. HCW and Staff Self-assessment

It is recommended all HCWs and other staff be advised to perform daily self-assessment for symptoms of influenza (see Appendix A) and not work if they are experiencing an ILI.  It is suggested staff be reminded of the importance of reporting their illness to those responsible for occupational health if they develop ILI while on duty.  It is advised that the organization encourage ill staff to report their illness and leave the workplace as soon as possible.

5. Hand Hygiene

It is recommended that HCWs and other staff, be advised to perform hand hygiene frequently (as per the healthcare organization’s policies) using either alcohol based hand rubs (60-90%) or soap and water.

6. Respiratory Hygiene (Respiratory Cough Etiquette):

It is advised that all HCWs and other staff be advised to perform respiratory hygiene practices (coughing into sleeve, using tissues, wearing a mask³ , if tolerated).  Those with ILI while at work should leave the workplace as soon as possible and continue to practice respiratory hygiene practices.

7. Fitness-for-work Specific to Pandemic (H1N1) 2009 Flu Virus

The recommendations related to the fitness-for-work evaluation in this guidance document are specific to Pandemic (H1N1) 2009 Flu Virus. Refer to the PHAC (formerly Health Canada) document titled Prevention and Control of Occupational Infections in Health Care, published in 2002, for recommendations on fitness-for-work in relation to other infectious agents. The following measures are recommended for organizations to have in place during Pandemic (H1N1) 2009 Flu Virus activity to assist in identifying HCWs and other staff who are fit-for-work (see a.), unfit-for-work (see b.), fit-for-work with restrictions due to medical conditions⁴ (see c.) or fit-for-work during a severe pandemic wave (see d.).

a. Fit-for-Work:  A HCW or other staff is considered Fit-for-work if he/she is asymptomatic as per the ILI Assessment Tool as outlined in Appendix A.

Individuals who are vaccinated against or recovered from Pandemic (H1N1) 2009 Flu Virus continue to daily self-assess for ILI (See Appendix A) and continue to use PPE to protect against new strains of influenza virus and other infectious respiratory agents.

b. Unfit-for-Work:  A HCW or other staff be considered unfit-for-work if he/she:

c. Fit-for-Work with Restrictions—HCW or staff at high risk for severe influenza disease or   complications:   

It is critical to recognize that it is often the unsuspected case that will ultimately expose the HCW or other staff to an infectious agent.  Far more important than work assignment restrictions as a measure of risk reduction are influenza immunization and the reinforcement of Point of Care Risk Assessment, together with full compliance with hand hygiene, routine practices and recommended additional precautions. It is recognized that there are cases of Pandemic (H1N1) 2009 influenza that have been transmitted to HCWs, or other staff, in the healthcare setting.

If possible, HCWs or other staff who are known to have medical conditions4 that place them at high risk for severe disease or complications if infected with Pandemic H1N1 influenza and who have not been immunized should not be assigned to designated influenza assessment clinics or hospital influenza units, or to an inpatient area experiencing an influenza outbreak or be present while an aerosol generating medical procedure (AGMP)⁵ is being performed on a patient suspected or confirmed to have Pandemic (H1N1) 2009 Flu Virus.

d. Fit-for-Work with Restrictions during a severe pandemic wave—HCW or other staff ill with influenza:

During a severe or prolonged pandemic wave or when multiple waves occur close together, and staffing shortages could compromise patient safety, organizations may need to consider some HCWs or other staff with symptoms of influenza “fit-for-work with restrictions”.

This should be decided in consultation with the OH and the IPC and guided by the overall level of absenteeism and availability of HCWs and other staff to work based on their susceptibility to Pandemic (H1N1) 2009 Flu Virus; their immunization status related to Pandemic (H1N1) 2009 Flu Virus; and their willingness/ability/need to use antiviral medications.

An ill HCW or other staff may be considered Fit-for-Work with Restrictions during a severe pandemic wave if ALL of the following apply:
The ill HCW or other staff:

• has mild influenza symptoms that are improving; and
• feels well enough to work; and
• will be assigned only to patients with influenza; and
• pays meticulous attention to hand hygiene and respiratory etiquette.

8. Definition of Occupational Exposure Specific to Pandemic (H1N1) 2009 Flu Virus

An occupational exposure occurs when:

• A HCW or other staff member is not wearing appropriate PPE (i.e. respirator/mask³ , depending on organizational policies or federal/provincial/territorial legislative requirements, and eye or face protection) when providing care within 2 metres of a coughing individual with *probable or **confirmed Pandemic (H1N1) 2009 Flu Virus who was unable to contain his/her cough.
• A HCW or other staff member is directly working with (e.g., working on the same shift on the same ward, taking breaks together and if within 2 metres) another HCW or staff member who leaves work ill due to an influenza like illness (see 4. above);
• A HCW or other staff member is not wearing appropriate PPE (i.e. respirator and eye or face protection) when present in the room or within the privacy curtain area while an AGMP⁵ is being performed on a * probable or ** confirmed case of Pandemic (H1N1) 2009 Flu Virus.

Risk of infection following exposure decreases significantly if a HCW or other staff member is immunized against Pandemic (H1N1) 2009 flu virus.

Careful consideration of the nature of the exposure is recommended as information regarding the duration of exposure is not known at this time.

9. Antiviral Treatment Specific to Pandemic (H1N1) 2009 Flu Virus

Recommendations for antiviral use in outbreak^*** settings can be found in Annex E and in Annex F of the Canadian Pandemic Influenza Plan.

Antiviral Treatment:
HCWs or other staff with medical conditions⁴ that place them at high risk for severe disease or complications if infected with influenza, who are symptomatic with ILI (suspect, probable, confirmed) should be provided with early treatment.
During a severe pandemic wave where safe staffing levels may be compromised, early treatment for ill HCWs or other staff, regardless of presence of medical conditions⁴ that place them at high risk for severe disease or complications if infected with influenza, may be considered under exceptional circumstances on a case-by-case basis by the treating clinician.

Routine post-exposure prophylaxis is not recommended due to the potential for drug resistance in the individual receiving the antiviral agent.  To date, almost all cases of oseltamivir resistance to Pandemic (H1N1) 2009 virus have been in individuals who had received post-exposure prophylaxis.  Resistant virus in an individual limits treatment options and could potentially lead to transmission of resistant virus to HCWs or other staff who could then transmit resistant virus to vulnerable patients in the healthcare setting or the broader community.

• In consultation with those with expertise in infectious diseases, public health, and occupational health, providing post exposure prophylaxis may be considered on a case-by-case basis in exceptional circumstances such as severe staff shortages, or exposure in settings where there is a high risk of severe outcome if patients are infected, e.g. high risk maternity units, bone marrow transplant units, dialysis units etc.

 

10. Reporting

It is recommended that when an organization becomes aware that a HCW or other staff is found to have an ILI, that IPC be notified of the area(s) where the individual was working.  Suspect or confirmed cases of Pandemic (H1N1) 2009 Flu Virus, including clusters of ill HCWs should be reported to Public Health either by OH or IPC as per the organization’s policy.

Any additional occupational illness reporting requirements such as to Workers’ Compensation Board and Ministry of Labour should be completed as per relevant federal/provincial/territorial legislative requirements and relevant privacy legislation.

References

1.  Influenza Statement 2008-9 National Advisory Committee on Immunization.  CCDR Vol 34 ACS-3, July 2008

Additional Information

Public Health Agency of Canada Surveillance Report

Centers for Disease Control and Prevention

ILI protocols and case-investigation form available at the following websites:
http://www.phac-aspc.gc.ca/eri-ire/pdf/02-SRI-Surveillance-Protocol_e.pdf http://www.phac-aspc.gc.ca/eri-ire/pdf/03-SRI-Report-Form_e.pdf

Nosocomial and Occupational Infections Section, Centre for Communicable Diseases and Infection Control, PHAC

Appendix A

Recommended ILI self-screening tool to be provided to

Health care workers and staff

• This tool is recommended for HCW, staff, contractors and volunteers etc. to self-assess for symptoms of influenza prior to arriving in the workplace.
• Do you have the following symptoms?:
  1. New onset or worsening of existing cough;
     AND/OR
  2. Fever (> 38°C) Note: Fever is not always present in Pandemic (H1N1) 2009
  3. PLUS
     Abrupt onset of any of the following:
     Sore throat
     Headache
     Joint pain
     Muscle pain
     Severe fatigue

If you answered yes to a and/or b, plus one of c you need further assessment by Occupational Health.

Appendix B

 

Cleaning
During an Aerosol Generating Medical Procedure (AGMP), aerosols may be created that will take a period of time to disperse from the environment. Based on data for other infectious aerosols, it is postulated that infectious aerosols with influenza virus will rapidly settle out of the air.  This will take varying lengths of time, dependent on the ventilation number of air exchanges in a room. The need to allow a period of time for dispersal of airborne contaminants is expected to be an issue only for AGMPs such as intubation, bronchoscopy, and open endotracheal suctioning (“high-risk” AGMP). The amount of time that should elapse after a high-risk AGMP has been conducted and before a hospital room may be entered without a respirator can be estimated based on the number of air changes in a room.  In the absence of specific studies on aerosols containing pandemic (H1N1) 2009 flu virus, the 'precautionary principle’ should apply. Appendix F Guidelines for Preventing the Transmission of Tuberculosis in Canadian Healthcare Facilities and Other Institutional Settings should be used as a guide for estimating time to remove airborne contaminants (e.g., A room with 6 air exchanges/hour, would take approximately 23 minutes to remove 90% of airborne contaminants compared to approximately 12 minutes for a room with 12 air exchanges/hour).

Cleaning staff should be advised as to when they may safely enter a room after performing a high risk AGMP.  Cleaning staff should wear a surgical mask and protective eyewear in addition to their usual cleaning garb upon entry once the appropriate elapsed time has occurred. If the room must be turned around before the time required to reduce 90% of airborne contaminants, a respirator and protective eyewear should be worn.

The usual hospital-grade cleaning and disinfecting agents are sufficient for environmental cleaning in the setting of H1N1.

Appendix C

Dental Offices
Interim guidance found in Infection Prevention and Control Measures for Health Care Workers in Acute Care Facilities can be equally applied in the dental office. Patients should be advised not to present for elective care when experiencing influenza like illness (ILI) symptoms and should be screened for ILI prior to undergoing any elective care or procedure in the dental office.

If care is required on an urgent basis for a patient with ILI symptoms suspected or confirmed to be due to H1N1, a risk assessment as to the likelihood of generating aerosols should be done and the appropriate droplet/respiratory protection applied based on that risk assessment.

Use of Polymerase chain reaction (PCR) to Discontinue Precautions
Decisions on when to discontinue precautions should be made in consultation with infectious diseases and/or medical microbiology consultants and infection control.  For those facilities that have access to PCR testing, PCR has been used to assist with this decision.   However, there is no published data to support an evidence based recommendation on how to use PCR to make decisions around stopping H1N1 precautions.  There is no established correlation between PCR positivity and transmissibility of influenza; further, PCR will detect non-viable virus particles, so a positive PCR cannot be used by itself as indicating ongoing viral transmissibility. Therefore, keeping patients on precautions until PCR negative may unnecessarily prolong the duration of precautions. However, it is very unlikely that there will be viral transmission when the PCR is negative.

H1N1 Contact Measures
The main method of transmission of influenza is through droplets. Hand contact with the patient and/or his/her environment may also be a means of transmission. However, there is no evidence that influenza may be transmitted through the HCW’s apparel. Therefore, gowns are not recommended as part of contact precautions for influenza, but are recommended as per Routine Practices as protection against splashes and sprays.

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