CalOSHA Aerosol Transmissible Disease Project

1. Cal/OSHA Aerosol Transmissible Disease Project CTCA 2006 Deborah Gold, MPH, CIH, dgold@hq.dir.ca.gov Bob Nakamura, MPH, CIH bnakamura@hq.dir.ca.gov Senior Industrial Hygienists, Cal/OSHA

3. The Cal/OSHA program 1970 Occupational Safety and Health Act established OSHA and NIOSH Permitted State Plans, but they must be as effective as federal OSHA 1973 California Occupational Safety and Health Act established Cal/OSHA from existing programs. There are 26 state plans, although 4 only cover public sector workers. OSH Act established a health and safety regulatory framework similar to wages and hours California operates a state plan under the authority of the Occupational Safety and Health Act and the California Occupational safety and Health Act. OSHA operates within the department of labor> Without going into the whole history of labor regulation, the philosophical basis of all labor regulation is that an individual worker is not bargaining on a level playing field with the employer, and therefore minimum standards (wages, hours, working conditions) must be setCalifornia operates a state plan under the authority of the Occupational Safety and Health Act and the California Occupational safety and Health Act. OSHA operates within the department of labor> Without going into the whole history of labor regulation, the philosophical basis of all labor regulation is that an individual worker is not bargaining on a level playing field with the employer, and therefore minimum standards (wages, hours, working conditions) must be set

4. The Cal/OSHA Program Division of Occupational Safety and Health (DOSH) Enforcement Consultation Engineering Services -- amusement rides, elevators, pressure vessels Mining and Tunneling OSH Standards Board OSH Appeals Board

5. Cal/OSHA and Infection Control Issued a special order to UCSF in 1970’s for Q fever Issued special orders for HBV vaccine in early 1990’s Cited Sanitation standard for sharps and other biological waste disposal prior to BBP standard

6. Cal/OSHA and Infection Control BBP standard (5193) came into effect 1/93, amended in 1997, 1999, 2001 Biosafety cabinet (5154.2), 1994 TB respirator standard (5147), 1998 Special orders on TB control to prisons, medical facilities, law enforcement, and a card club Cal/OSHA P&P 47 adddresses TB

7. OSHA vs. Other Public Health Approaches OSHA Mission is to protect individual workers Medical surveillance for the protection of the employee regulatory enforcement mechanism Risk at work is often more concentrated than risks to the general public Employees jobs require them to take risks to protect others. Public Health Mission is to protect the overall public’s health Medical surveillance to protect the public Usually relies on guidelines, and enforces through licensing Develops risk reduction measures for the general public, don’t always focus on specific occupational risks to individual workers

8. What is an ATD Aerosol transmissible diseases (ATD) are diseases that are spread through the air by droplets containing infectious pathogens. Infection control professionals distinguish between diseases primarily spread by: larger droplets (near field) >5 microns (droplet precautions) Small droplets, droplet nucleii, dusts containing the pathogen (airborne isolation)

9. Airborne Infectious Diseases Airborne spore release (e.g. anthrax) until decon Chickenpox (Varicella) Highly pathogenic avian influenza Herpes zoster (varicella-zoster, disseminated disease, per CDC) Measles (rubeola) Monkeypox Novel or Unknown pathogen SARS (Severe Acute Respiratory Syndrome) Smallpox Tuberculosis

10. Some Droplet diseases Diptheria Influenza Meningococcal disease Mumps Mycoplasma pneumonia Pertussis Plague (pneumonic) Rubella SARS Viral hemorrhagic fevers

11. What do ATDs have in common? Initial symptoms and signs are often not specific E.g. TB initially presenting as “pneumonia” Many pose significant risks, particularly to health care workers – e.g. TB There is often an airborne route, even for diseases classified as droplet It is currently believed that cough etiquette (respiratory hygiene) can reduce the spread of disease, particularly in the period prior to initiation of appropriate treatment.

12. Other Important Concepts Exposure Incident – employees exposed without control measures to a confirmed case of a Reportable ATD, as listed in Title 17. Precautionary Removal – when an employee is NOT sick, but is required to be removed from the workplace during an incubation period because the employee may be infectious Source Control includes respiratory hygiene/ cough etiquette Novel or Unknown Pathogen – e.g. SARS in 2003

13. Draft ATD Standard -- Application Applies to health care and other high-risk environments and occupations Law enforcement, corrections, emergency medical, homeless shelters, laboratories Animal eradication workers for avian flu etc. Like new TB guidelines, acknowledges that some employers will only provide screening, and then pass the patient along to a hospital etc.

14. Draft ATD Standard -- Concepts Early identification and broad source control measures (respiratory hygiene) Tracks HICPAC recommendations for specific precautions Facilities that provide services to “airborne infectious” disease cases must have engineering controls, respirators, etc.

15. Four Types of Employers Hospitals, other work settings which perform: evaluation, diagnosis, treatment, transport, housing or management of persons requiring airborne infection isolation; high hazard procedures performed on suspect or confirmed cases; decontamination or management of persons contaminated as a result of a release of biological agents; autopsies or embalming procedures on human cadavers potentially infected with aerosol transmissible pathogens.

16. Four Types of Employers (cont) Patients, clients, residents etc. are screened for airborne infectious diseases and referred if indicated (Referring Employers – subsection (b)) Laboratories (subsection (e)) Contact with infected animals (subsection (i))

17. Referring Employers Establish written procedures (may be part of Injury and Illness Prevention Program or other program) Source control (exception for field operations where not feasible) Identification of suspect airborne cases Referral to appropriate facilities, within 5 hours. Exceptions: If initial encounter is after 3:30 p.m. referral or transfer by11:00 a.m next morning If no appropriate facility available and consult with LHO If medically contra-indicated

18. Referring Employers (cont) Measures to protect employees during time suspect case is in workplace Procedures to communicate with other employers and to receive info from diagnosing facility Vaccinations as recommended by CDC or CDHS Procedures for exposure incidents Training, record-keeping and annual review of procedures

19. Employers Providing Services to Airborne Infectious Disease Cases Subsection (c) – Written program Subsection (d) – Control measures Initial identification of cases, and referral or transfer when necessary Use of engineering and work practice controls, particularly for high hazard procedures Airborne infection isolation when appropriate, meeting requirements from building code (OSHPD) or CDC Personal Protective Equipment based on CDC recommendations (includes surgical masks for droplet precautions)

20. Employers Providing Services to Airborne Infectious Disease Cases Subsection (f) – Respiratory protection For airborne infectious diseases Must meet requirements of section 5144 (and if applicable 5192) as well N95 is minimum, for high hazard procedures more protective respirators unless would interfere in successful performance of tasks Employees must be medically evaluated (appendix B contains reduced questionnaire) Fit tests initially, at least annually for high hazard Permits every 2 years for non-high hazard procedures until 2012

21. Employers Providing Services to Airborne Infectious Disease Cases Subsection (g) Medical Surveillance Vaccinations as recommended by CDC or CDHS TB testing at least annually, or as recommended by CDC or CDHS (permits blood tests or PPD); Conversions referred to PLHCP Provisions for exposure incidents Report to LHO of Title 17 reportable diseases Employers to consult infection control expert or LHO on exposure incidents Precautionary removal provisions for infection control purposes

22. Employers Providing Services to Airborne Infectious Disease Cases Subsection (h) Training At initial assignment and at least annually Train on all applicable elements of the standard Additional training for surge and emergencies Respirator users must be trained in accordance with 5144 Opportunity for interaction with trainer Trainer must be knowledgeable Training must be appropriate in language, literacy and education to the employees

23. Employers Providing Services to Airborne Infectious Disease Cases Subsection (j) – Record keeping Medical record for each exposed employee, maintained confidential, comply with 3204 Training records maintained for 3 years Plan implementation, including: Ventilation testing and other engineering controls Exposure incidents Annual review of plan and employee involvement Respirators in accordance with 5144

24. Laboratories – Subsection (e) Applies where laboratory operations capable of aerosolizing ATP-L are performed AND where employees do not have direct contract with suspect or confirmed cases Requires biosafety plan, biosafety officer(s) and BSL -3 type control measures Ref. BMBL (Biosafety in Microbiological and Biomedical Laboratories)

25. Role of LHO in Draft Standard Employer with suspect or confirmed Airborne case may consult with LHO to find placement or for advice re interim control measures Employers to have effective procedures for reporting cases to the LHO Employers to consult with infection control practitioner or LHO to assess exposure incidents. In current draft, may designate a workplace as at elevated risk for ATD’s.

26. Cal/OSHA Rulemaking Process Advisory meetings and other pre-rulemaking activities Proposal goes to Standards Board staff After editing and review, Standards Board forwards it to the Office of Administrative Law for publication 45 day public comment period, with a hearing at the end If there are changes, one or more 15 day notices for public comment Board votes on standard, if adopted, forwards to OAL for review for compliance with the Administrative Procedures Act.

27. ATD Project Status 5-06 We are still in pre-rulemaking – there is no formal proposal We are still soliciting and accepting feedback on the April 7, 2006 draft, but need it very soon Additional advisory meetings are scheduled for 5/19 (poultry), 5/24 (non-traditional) 5/31(law enforcement and corrections) We expect to send the proposal to the Standards Board by the end of May We hope it will be noticed for public comment in July or August

28. Find Cal/OSHA on the Web Advisory committee webpage: http://www.dir.ca.gov/dosh/DoshReg/advisory_committee.html Respiratory protection regulation http://www.dir.ca.gov/Title8/5144.html Respiratory Protection in the Workplace http://www.dir.ca.gov/dosh/dosh_publications/respiratory.pdf DOSH TB P&P 47 (Tuberculosis) http://www.dir.ca.gov/DOSHPol/P&PC-47.HTM

29. Thank you TB Controllers for protecting the health of our communities