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OSHA Publishes Revised Avian
Flu Guidelines
OSHA has published revised
healthcare worker protection guidelines titled "OSHA Guidance
Update on Protecting Employees from Avian Flu (Avian Influenza)
Viruses." These guidelines are being enforced using the
"General Duty Clause", section 5(a)(1) of the Occupational
Safety and Health Act. Section 5(a)(1) requires employers to
provide a workplace free of "recognized hazards." Since
everyone knows about Avian Flu, it is a recognized hazard. Simply
stated, the revised guidelines are not a law, but if you don't
follow them you can be cited and fined under section 5(a)(1).
The portion of the 76 page
document which deals with healthcare workers and laboratory workers
is reproduced below. A complete copy of the document can be downloaded
by right clicking on the following link and then left clicking
on "Save Target As.":
http://www.osha.gov/OshDoc/data_AvianFlu/avian_flu_guidance_english.pdf
Guidance for
Healthcare Workers Who Treat Patients with Known or Suspected
AI
The CDC has issued Interim
Recommendations for Infection Control in Healthcare Facilities
Caring for Patients with Known or Suspected Avian Influenza.
This document contains the following recommendations:
All patients who present
to a healthcare setting with fever and respiratory symptoms should
be managed according to recommendations for:
+ Respiratory Hygiene/Cough
Etiquette in Healthcare Settings (see: www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm);
and
+ questioned regarding their recent travel history.
Patients with a history of
travel within 10 days to a country with AI activity and who are
hospitalized with a severe febrile respiratory illness, or are
otherwise under evaluation for AI, should be managed using isolation
precautions identical to those recommended for patients with
known Severe Acute Respiratory Syndrome (SARS). These include:
Standard Precautions
Hand hygiene is absolutely essential.
+ Before and after all patient
contact.
+ As soon as possible after contact with items contaminated or
potentially contaminated with respiratory secretions.
Contact Precautions
+ Use gloves and gown for
all patient contact.
+ Use disposable equipment (blood pressure cuffs, thermometers)
or equipment that can be disinfected before use with another
patient (stethoscopes, etc.).
Droplet Precautions
+ Wear goggles or face shields
when within 3 feet of the patient.
Important
considerations:
+ Face shields are insufficient
protection for airborne hazards or for facial splashes.
Airborne
Precautions
Place the patient in an airborne
infection isolation room.
+ Airborne infection isolation
rooms should have monitored negative air pressure in relation
to the corridor, with 6 to 12 air changes per hour, and
+ should exhaust air directly to the outside or have recirculated
air filtered by a high efficiency particulate air (HEPA) filter.
Keep the doors to the patient room closed; this protects other
employees who are nearby.
If an airborne infection
isolation room is unavailable, contact the healthcare facility
engineer to assist or use portable HEPA filters (see Environmental
Infection Control Guidelines at www.cdc.gov/ncidod/hip/enviro/guide.htm)
to augment the number of air changes per hour.
Use a fit tested respirator, at least as protective as a National
Institute for Occupational Safety and Health (NIOSH)-approved
N-95 filtering facepiece (i.e., disposable) respirator, when
entering the room.
Important
considerations:
OSHA requires that respirators
must be used in the context of a complete respiratory protection
program (RPP). This includes training, fit testing, and user
seal checks to ensure appropriate respirator selection and use.
To be effective, tight-fitting respirators must have a proper
sealing surface on the wearer's face. The elements of a complete
RPP are described in detail in 29 CFR 1910.134 (www.osha.gov/SLTC/etools/respiratory/oshafiles/otherdocs.html).
For information on respirators,
see the following:
+ www.osha.gov/SLTC/etools/respiratory/index.html, and
+ www.cdc.gov/niosh/npptl/topics/respirators.
Transmission
Prevention Strategies in Healthcare Settings
Place patients that are AI-infected
and those that are suspected of being AI-infected together in
the same room if private rooms are not available. This would
only be a likely scenario if there were a major avian influenza
outbreak in your area.
If possible, try not to place
patients with seasonal influenza and those with AI in the same
room. Although the risk is relatively small, the sharing of the
same room by such patients would increase the chances of co-infection
of patients with the two viruses and this could lead to viral
reassortment of genes and the possible emergence of a pandemic
virus.
Minimize transportation of
influenza patients outside of room.
Limit the number of healthcare
workers caring for influenza patients.
Limit the number of visitors
to influenza patients.
For additional information
regarding these and other healthcare isolation precautions, see
the Guidelines for Isolation Precautions in Hospitals (www.cdc.gov/ncidod/hip/isolat/isolat.htm).
The precautions for healthcare employees listed above should
be continued for 14 days after onset of symptoms or until:
+ an alternative diagnosis
is established that explains the
patient's illness or
+ diagnostic test results are negative for influenza A virus.
Patients managed as outpatients
or hospitalized patients discharged before 14 days with suspected
AI should be isolated in the home setting on the basis of principles
outlined for the home isolation of SARS patients (see www.cdc.gov/ncidod/sars/guidance/i/pdf/i.pdf).
Vaccination
of Healthcare Workers against Human Influenza
Healthcare workers involved in the care of patients with documented
or suspected AI should be vaccinated with the most recent seasonal
human influenza vaccine. In addition to providing protection
against the predominant circulating influenza strains, this measure
is intended to reduce the likelihood of a healthcare worker being
co-infected with both human and AI viruses, where genetic reassortment
could take place, leading to the emergence of potential pandemic
strains.
Important
considerations:
Influenza vaccination of
U.S. healthcare workers remains below 40% despite the vaccine's
safety and effectiveness. A recent publication clearly describes
the benefits of yearly influenza vaccination of healthcare workers.
Yearly influenza vaccination of healthcare workers has been demonstrated
to reduce absenteeism, nosocomial influenza transmission, and
the associated economic losses and disruption of routine operations.
Surveillance
and Monitoring of Healthcare Workers
Healthcare workers should
be instructed to be vigilant for symptoms of AI infection for
at least one week after their last exposure to AI-infected patients.
Symptoms have ranged from typical human influenza-like symptoms
(fever, cough, sore throat, and muscle aches) to eye infections
(conjunctivitis), pneumonia, severe respiratory diseases (such
as acute respiratory distress syndrome), and other severe and
life-threatening complications.
Important
considerations:
Human AI infections are manifested
in different ways dependent on the health status of the individual
before infection and pathogenicity of the AI strain. Although
the symptoms are, in general, flu-like, they may vary.
Individuals infected with the H7N7 virus that caused the outbreak
in the Netherlands in 2003 most frequently had conjunctivitis
only. (See Appendix B for more specific information).
Hospitalized individuals infected with strains of the H5N1 subtype
most frequently had fever combined with a cough and also had
difficulty breathing and/or diarrhea. Conjunctivitis was rare.
See Appendix F for specific details on some of the common symptoms
of patients infected with different strains of H5N1.
Healthcare workers who become
ill should do the following:
Seek medical care but prior to arrival notify their healthcare
provider that they may have been exposed to AI.
Notify the occupational health and infection control
personnel at their facility.
With the exception of visiting
a healthcare provider, stay home until 24 hours after resolution
of fever, unless:
+ an alternative diagnosis is established that explains the patient's
illness; or
+ diagnostic tests are negative for influenza A virus.
While at home, ill persons should practice good respiratory and
hand hygiene to lower the risk of transmitting the virus to others.
For more information, visit the following CDC websites:
+ Cover Your Cough (www.cdc.gov/flu/protect/covercough.htm)
+ Hand Hygiene Guidelines
Fact Sheet (www.cdc.gov/od/oc/media/pressrel/fs021025.htm).
Guidance for
Laboratory Employees
CDC has made the following
recommendations for laboratory testing for H5N1 in a website
document titled, Updated Interim Guidance for Laboratory Testing
of Persons with Suspected Infection with Avian Influenza A (H5N1)
Virus in the United States.
Manipulating highly pathogenic
avian influenza (HPAI) viruses in biomedical research laboratories
requires caution because some strains may pose increased risk
to laboratory employees and have significant agricultural and
economic implications. Biosafety Level 3 (BSL 3) and Animal Biosafety
Level 3 (ABSL 3) practices, procedures and facilities are recommended
along with clothing change and personal showering protocols (referred
to as enhanced BSL 3 practices). Loose-housed animals infected
with HPAI strains must be contained within BSL 3 (Ag) facilities.
Negative pressure, HEPA-filtered respirators or positive air-purifying
respirators are recommended for highly pathogenic avian influenza
(HPAI) viruses with potential to infect humans. The HPAI viruses
are agricultural Select Agents requiring registration of personnel
and facilities with the lead agency for the institution (CDC
or USDA-APHIS). An APHIS permit is also required. Additional
containment requirements and personnel practices and/or restrictions
may be added as conditions of the permit.
Important
considerations:
For more information about
BSL levels, consult the CDC publication titled Biosafety in Microbiological
and Biomedical Laboratories (BMBL 4th edition) available at:
www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4toc.htm. A fifth edition
is scheduled for release in late 2006.
If human specimens being
examined for the presence of the AI-virus contain blood or body
fluids that contain blood, they must be handled following the
Bloodborne Pathogens standard (29 CFR 1910.1030). Complete details
of the standard are available at: www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051
Polymerase chain reaction
(PCR) assays or commercial antigen detection testing can be conducted
on clinical specimens from suspect H5N1 cases using standard
BSL 2 work practices in a Class II biological safety cabinet.
BSL 2 laboratory conditions include BSL 1 procedures plus:
+ Biohazard warning signs;
+ Use of leakproof transport containers; and
+ Use of biosafety cabinets (Class II).
Note: Commercial antigen testing and RT-PCR are not appropriate
substitutes for respiratory specimen virus isolation.
CDC recommends that virus
isolation studies on respiratory specimens from patients suspected
of having H5N1 infections should only be conducted under enhanced
BSL 3 conditions.
If a clinical laboratory
does not have enhanced BSL 3 facilities, virus isolations should
not be ordered for patients suspected of having H5N1 infection.
FDA regulations apply to
devices used to test human specimens for avian influenza. Instructions
for use may address other precautions, and use of some avian
influenza tests may be subject to additional regulatory requirements.
For more information contact the Office of In Vitro Diagnostic
Evaluation and Safety at: 240-276-0484.
Use respiratory protection
as determined by risk assessment.
OSHA requires that respirators
must be used in the context of a complete respiratory protection
program (RPP). This includes training, fit testing, and user
seal checks to ensure appropriate respirator selection and use.
To be effective, tight-fitting respirators must have a proper
sealing surface on the wearer's face. The elements of a complete
RPP are described in detail in 29 CFR 1910.134 (www.osha.gov/SLTC/etools/respiratory/oshafiles/otherdocs.html).
For information on respirators,
see the following:
+ www.osha.gov/SLTC/etools/respiratory/index.html, and
+ www.cdc.gov/niosh/npptl/topics/respirators/.
Medical Monitoring
Laboratory employees should
be instructed to be vigilant for symptoms of AI infection for
at least one week after their last exposure to AI-infected materials.
Symptoms have ranged from typical human influenza-like symptoms
(fever, cough, sore throat, and muscle aches) to eye infections
(conjunctivitis), pneumonia, severe respiratory diseases (such
as acute respiratory distress syndrome), and other severe and
life-threatening complications.
Important considerations:
Human AI infections are manifested
in different ways dependent on the health status of the individual
before infection and pathogenicity of the AI strain. Although
the symptoms are, in general, flu-like, they may vary.
Individuals infected with the H7N7 virus that caused the outbreak
in the Netherlands in 2003 most frequently had conjunctivitis
only (See Appendix B for more specific information).
Hospitalized individuals
infected with strains of the H5N1 subtype most frequently had
fever combined with a cough and also had difficulty breathing
and/or diarrhea. Conjunctivitis was rare. See Appendix F for
specific details on some of the common symptoms of patients infected
with different strains of H5N1.
Laboratory employees who
become ill should do the following:
+ Seek medical care but prior to arrival notify their healthcare
provider that they may have been exposed to AI.
+ Notify the occupational
health and infection control personnel at their facility.
+ With the exception of visiting
a healthcare provider, stay home until 24 hours after resolution
of fever, unless:
+ an alternative diagnosis is established that explains the patient's
illness; or
+ diagnostic tests are negative for influenza A virus.
While at home, ill persons
should practice good respiratory and hand hygiene to lower the
risk of transmitting virus to others. For more information, visit
the following CDC websites:
+ Cover Your Cough (www.cdc.gov/flu/protect/covercough.htm)
+ Hand Hygiene Guidelines Fact Sheet (www.cdc.gov/od/oc/media/pressrel/fs021025.htm)
Employee
Training
All employees with potential
occupational exposure, as describedin this document, should be
trained on the hazards associatedwith exposure to influenza A
(H5N1) and be familiar with theprotocols in place in their facility
to isolate and report cases orreduce exposures.
Source: OSHA Guidance Update on Protecting
Employees from Avian Flu (Avian Influenza) Viruses
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