Guidance: Infection prevention and control measures for Health Care Workers Providing Care or Service in the Home

Posted: November 4, 2009

Human Cases of Pandemic (H1N1) 2009 Flu Virus

This fact sheet has been developed to provide guidance to health care workers (HCWs) in the infection prevention and control management of suspected or confirmed cases with Pandemic (H1N1) 2009 Flu Virus. This guidance is for home care settings where care or service is provided by regulated and unregulated health care workers and health care agency volunteers² . While it is expected that this document will provide helpful information to all HCWs, its primary audience is those individuals who are responsible for Infection Prevention and Control in home settings where healthcare is delivered.

This Guidance is designed to help slow (mitigate) the transmission of this virus; it is expected that the infection prevention and control recommendations (particularly recommendations related to respiratory protection) may change as further information about the epidemiology (e.g., mode of transmission) and clinical course (e.g., mild or severe disease) of this virus is available and the outbreak evolves. In this document, a point of care risk assessment approach is used to guide decisions regarding the type of droplet precautions/respiratory protection to apply. Additionally, this document assumes that measures 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 are in place.

This guidance is being provided by the Public Health Agency of Canada (PHAC) in response to the ongoing outbreak of Pandemic (H1N1) 2009 Flu Virus.  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 content of this document has been informed by discussion with and technical advice provided by the Infection Control Expert Advisory Group to PHAC.

At this time the evidence suggests that the median incubation period for Pandemic (H1N1) Flu Virus is 4 days and individuals may remain infectious for up to 7 days. These timelines are similar to prior experience with human swine influenza viruses. 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 occur. The clinical picture to date in Canada, of human illness from Pandemic (H1N1) 2009 Flu Virus for most individuals is one of mild disease. However, some will experience moderate or severe disease. Pandemic (H1N1) 2009 Flu Virus is susceptible to the antiviral agents, oseltamivir and zanamivir, which represent therapeutic options for individuals in whom treatment is indicated. This information on morbidity and mortality and treatment options has been taken into account when developing this guidance. One goal of this guidance is, using a risk assessment approach, to support use of personal protective equipment most appropriate to the risk associated with the care to be provided, thereby protecting limited resources for those situations where protection is most needed.

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

• Acute onset of respiratory illness with cough and/or fever (in children under 5 years of age and adults 65 years of age and older fever may not be present with infection; in children under 5 years of age GI symptoms may also be present)
• And one or more of: headache, sore throat, arthralgia, myalgia, or prostration that could be due to influenza.

It should be noted that these screening criteria above will be updated as the epidemiological situation evolves.

Until the etiology of the ILI is known, in addition to Routine Practices, infection prevention and control measures  for all ILI cases suspected or confirmed to be due to the Pandemic (H1N1) 2009 Flu Virus should include:

1. Education
2. Source Controls
3. Respiratory Hygiene (also known as Respiratory Cough Etiquette)
4. Hand Hygiene
5. Contact Precautions
6. Droplet precautions/Respiratory protection
7. Client Care Environment

1. Education

• Ensure that employees and volunteers who are providing home care and service know and are practising the recommendations in this guidance with clients who have ILI symptoms. The Routine Practices and Additional Precautions as outlined below are to be practiced from symptom(s) onset until 7 days after symptoms started.
• Educate clients, caregivers and household members how to reduce the spread of Pandemic (H1N1) 2009 Flu Virus in the home and community.

2. Source Controls

Applying source controls as the first strategy in protecting employees and volunteers from exposure to infectious agents in the home care setting where health care and service is delivered cannot be overemphasized.

1. Determine whether your organization will have volunteers provide care and service to clients with ILI. The following recommendations apply to all employees and volunteers who provide care for clients with ILI.
2. Prioritize delivery of care and service to that which is essential, especially care and service to clients for whom hospitalization may be prevented for influenza or any other medical condition.
3. Consider assigning employees and volunteers who have recovered from Pandemic (H1N1 2009) Flu Virus (cohorting) to make visits specifically for those clients with ILI, if available and feasible.
4. Ensure that employees and volunteers have access to alcohol based hand rubs and sufficient personal protective equipment for provision of care and service to clients with ILI.
5. Implement telephone screening of clients to identify whether the client, caregiver or any household members have ILI symptoms prior to arriving at the home. Cancel or postpone the home visit if medically feasible until the period of communicability (7 days from the onset of symptoms) has passed.
6. If telephone screening is not possible, maintain a distance of 2 metres from the ill client, caregiver and household members when screening. Screen at the entrance to the client’s home or before entering the client care area.
7. Identify whether the care or service can be provided without direct contact with the ill individual(s) (e.g. the employee or volunteer will remain more than 2 metres from the client). For example, unregulated employees performing non-personal home support duties (e.g. laundry, meal preparation and house cleaning) should be able to avoid contact with ill individuals. For volunteers delivering meals or medications, consider whether the item can be left with a family member who is well or placed inside the door of the home.
8. If it is the caregiver or a family member(s) who has ILI, request that the ill individual(s) not enter the room/care area where the care/service is being provided to the client. At the least, the ill family member(s) should maintain a distance of 2 metres from the employee and volunteer at all times.
9. Teach clients, caregivers and family members to maintain a 2 metres distance from the ill person (e.g. establish a care location for the suspected ILI person to rest away from others)
10. Educate clients on measures to take to prevent transmission of influenza in their homes (frequent hand hygiene and cleaning of high touch surfaces (e.g. door knobs) and bathrooms).

3. Respiratory Hygiene (Respiratory Cough Etiquette):

1. Teach clients to perform hand hygiene (See #4 below).
2. Teach clients with ILI how to perform respiratory hygiene practices (coughing into sleeve, using tissues, wearing a mask³ ).
3. Ask clients with ILI to wear a mask³ (if tolerated) if they are unable to perform cough etiquette when employees and volunteers are present.
4. Appropriately discard used PPE (if disposable) after client care. Clean and disinfect eye protection (if re-usable) before leaving client homes, as per organizational policy.
5. Appropriately clean and disinfect reusable medical equipment prior to leaving client homes, as per organizational policy.

4. Hand Hygiene

1. Employees and volunteers should perform hand hygiene frequently (as per the healthcare organization’s policies) using either alcohol based hand rubs (60-90%) or soap and water.

5. Contact Precautions

1. Employees and volunteers should wear gloves when entering the room of an individual with ILI.
2. Gowns are to be worn as for Routine Practices.
3. Gloves and gowns should be removed when leaving the client care area, taking care to avoid self-contamination. Gloves and gowns (if disposable) should be discarded in the household garbage. Reusable gowns should be placed in a bag or other receptacle for reprocessing, as per organizational policy.
4. Employees and volunteers should use alcohol based hand rubs or soap and water after removing gowns and gloves and after leaving the client care area and home.

6. Droplet Precautions/Respiratory Protection  (Mask³/N95 Respirator; and eye or face protection)

Employees and volunteers should use droplet precautions/respiratory protection when within 2 metres of an individual (client, caregiver, or household member) with ILI. The choice between droplet precautions (a mask³) and respiratory protection (N95 respirator) should be based on the following:

1. A mask³ should be worn if within 2 metres of a client, caregiver or household member with ILI.
2. An N95 respirator should be worn if conducting an aerosol-generating medical procedure (AGMP⁴ ) on a client with ILI,
3. The mask³ or N95 respirator should be removed by the straps, being careful not to touch the mask or respirator itself, after leaving the client care area and safely discarded in household garbage.
4. Whenever a mask³ or N95 respirator is required, the employee and volunteer should also wear eye or face protection. Eye or face protection should also be removed  when leaving the client care area and safely discarded in household garbage (if disposable) or appropriately cleaned and disinfected before leaving the client’s home (if reusable), as per organizational policy.
5. Employees and volunteers should perform hand hygiene before and after removing mask, respiratory protection and face/eye protection, and after leaving the client’s care area and the home.

7. Client Care Environment

1. Encourage clients, caregivers or family members to establish a care location for the person with ILI to rest away from others, preferably in a well-ventilated (e.g. open window) room of their own ( http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/guidance-orientation-05-03-eng.php.
2. Appropriately clean and disinfect reusable medical equipment prior to leaving client homes, as per organizational policy.

References and Additional Information:

• Public Health Agency of Canada website at:
  http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/surveillance-eng.php
• Centers for Disease Control and Prevention, at:
  http://www.cdc.gov/h1n1flu/update.htm
• ILI protocols and case-investigation form available at the following websites: http://www.phac-aspc.gc.ca/eri-ire/pdf/02-ILI-Surveillance-Protocol_e.pdf
  http://www.phac-aspc.gc.ca/eri-ire/pdf/03-ILI-Report-Form_e.pdf
• Nosocomial and Occupational Infections Section, Centre for Communicable Diseases and Infection Control, PHAC http://www.phac-aspc.gc.ca/nois-sinp/index-eng.php
• How to look after someone at home with H1N1 Flu Virus
  http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/guidance-orientation-05-03-eng.php

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