2009 H1N1 Influenza DOSH Directive 11.70

1. 2009 H1N1 InfluenzaDOSH Directive 11.70

2. H1N1 Influenza • In April 2009, a novel H1N1 influenza A strain of swine origin was identified in Mexico. It was designated as novel because it was genetically distinct from the circulating seasonal flu virus and therefore humans had little or no immunity to it and there was no vaccine to protect against it.

3. State Plan Policy • States with OSHA-approved State Plans must adopt OSHA’s enforcement policies or have their own enforcement policies that must be at least as effective as OSHA’s. • DOSH has elected to adopt its own Directive closely following OSHA’s.

4. Publications Referenced

5. Purpose • …to minimize high to very high occupational exposure risk to the virus identified as 2009 H1N1 influenza of workers whose occupational activities involve contact with patients or contaminated material in a healthcare or clinical laboratory setting.

6. Scope • Inspections will be conducted in workplaces where healthcare workers will likely have high to very high risk exposure to 2009 H1N1 influenza. Hospitals, medical clinics, doctors’ and dental offices are most likely to have these type exposures.

7. Scope (continued) • Non-healthcare settings that provide clinical services may also be covered, including: • Schools • Correctional facilities • Reference available CDC guidelines for specific settings

8. DOSH Directive 11.70 Effective Date: 12-23-2009 Subject: Enforcement Procedures for High to Very High Occupational Exposure Risk to 2009 H1N1 Influenza

9. Definition of a Healthcare Worker • Healthcare personnel -all persons whose occupational activities involve contact with patients or contaminated material in a healthcare or clinical laboratory setting.” … many of which include patient contact even though they do not involve direct provision of patient care, such as dietary and housekeeping services. • Work settings include: • Inpatient and outpatient facilities, • Home healthcare settings, and • Institutional settings such as schools and correctional facilities.

10. Very High Risk Exposure • A job task or activity involving a medical or laboratory procedure during which there is a potential of occupational exposure to high concentrations of suspected or confirmed 2009 H1N1 influenza virus. • Performance of aerosol-generating procedures on patients with suspected or diagnosed 2009 H1N1 influenza; or • Manipulations of influenza laboratory specimens that may create aerosols.

11. Aerosol-Generating Procedures • The aerosol-generating procedures include: • Bronchoscopy • Sputum induction • Endotracheal intubation and extubation • Open suctioning of airways • Cardiopulmonary resuscitation • Autopsies

12. High Exposure Risk • A job task or activity involving a high potential for exposure to suspected or confirmed 2009 H1N1 influenza virus, such as: • Healthcare workers who are in close contact [working within 6 feet of suspected or confirmed patients or entering into a small enclosed airspace shared with the patient (e.g., size of an average patient room)]. • Staff transporting suspected or confirmed 2009 H1N1 patients in enclosed vehicles (such as, emergency responders).

13. Hierarchy of Controls • Facilities should use a hierarchy of controls approach to prevent exposure of healthcare personnel and patients and prevent influenza transmission within healthcare settings. • Eliminating the potential source of exposure ranks highest in the hierarchy of controls.

14. Hierarchy of Controls (continued) • Engineering controls • Engineering controls rank second in the hierarchy of controls. They are particularly effective because they reduce or eliminate exposures at the source and many can be implemented without placing primary responsibility of implementation on individual employees. In addition, these controls can protect patients as well as personnel

15. Hierarchy of Controls (continued) • Administrative controls • Administrative controls are required work practices and policies that prevent exposures. As a group, they rank third in the hierarchy of controls because their effectiveness is dependent on consistent implementation by management and employees

16. Inspection Scheduling Compliance Inspections • Focus is on hospitals, emergency medical centers, doctors’ and dental offices and clinics. • Inspections will be opened in response to formal complaints and referrals • Where complaints or referrals are received regarding non-healthcare settings or regarding medium and low risk exposure risk response will be via phone/fax.

17. Inspection Procedures Opening Conference • CSHOs shall establish whether the workplace has employees who may carry high or very high exposure risk. • CSHOs must request information on any hazard assessment or exposure risk assessments performed at the facility for the following: • Any assessment to determine the presence of hazards which necessitate the use of personal protective equipment (PPE) • Initial respiratory hazard evaluation. • Exposure risk assessment to determine employees’ exposure risk categories.

18. Opening Conference (continued) • CSHOs shall initially determine whether the employer has a written pandemic influenza plan as recommended by the CDC. • The evaluation of an employer’s pandemic influenza plan may be based upon written programs and, in a hospital, a review of the infection control data. • Other information which may be reviewed includes: • medical records related to worker exposure incident(s), • OSHA 300 log, and • any other pertinent information or documentation deemed appropriate by the CSHO.

19. Walkaround • CSHOs shall use professional judgment in determining which areas of the facility will be inspected (e.g., emergency rooms, respiratory therapy areas, bronchoscopy suites, morgue). • Photographs or videotaping where practical shall be used for case documentation…under no circumstances shall photographing or videotaping of patients be done, and • CSHOs must take all necessary precautions to assure and protect patient confidentiality.

20. Compliance Officer (CSHO) Protection • CSHOs shall use judgment and exercise caution: • Conduct inspections in a manner that minimizes or prevents exposure (for example, view employee work tasks through an observation window). Example: observe procedures

21. CSHO Protection (continued) • CSHOs shall not enter rooms occupied by 2009 H1N1 influenza patients or airborne infection isolation rooms (AIIRs) to evaluate compliance. • If CSHOs must enter a vacant AIIR, sufficient time must lapse before entry can be made. (For information on clearance rates under differing ventilation conditions, see http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm). • CSHOs shall practice social distancing (such as maintaining at least 6 feet of distance), if possible, while conducting interviews with employees or patents with suspected influenza .

22. CSHO Protection (continued) • CSHOs must ask employers if there are any PPE requirements. Where CSHOs need to test ventilation or air flow of an isolation room – CSHOs shall wear a half-mask negative pressure respirator with at least N95 filters. • CSHOs shall wash their hands with soap and water after each inspection or use hand sanitizers if handwashing facilities are not immediately available.

23. Records Review • Access to employee medical and exposure records. • Follow the direction contained in WAC 296-802-500 when accessing employee medical records. • Consult with the DOSH Occupational Nurse Consultant for further guidance. Note: HIPAA does not apply to employee health information. [p. 12]

24. Records Review (continued) • OSHA 300 Log • Illnesses due to the 2009 H1N1 influenza are not considered a common cold or seasonal flu. • Employers are responsible for recording cases of 2009 H1N1 illness if all of the following requirements are met: • the case is a confirmed case of 2009 H1N1 illness as defined by CDC; • the case is work-related as defined by 296-27-01101; and • the case involves one or more of the recording criteria set forth in 296-27-01107 (e.g., medical treatment, days away from work ).

25. Review 296-27-01107-General Recording Criteria • An injury or illness is recordable if it results in one or more of the following: • Death • Days away from work • Restricted work activity • Transfer to another job • Medical treatment beyond first aid • Loss of consciousness • Significant injury or illness diagnosed by a Physician or Other Licensed Health Care Professional (PLHCP)

26. Citation Guidelines • Applicable Standards • 296-800-110 Safe Place Standard. • 296-800-11045 Biological Agents • 296-800-140 Accident Prevention Program • 296-27 Recordkeeping and Reporting. • 296-800-160 Personal Protective Equipment. • 296-842 Respirators • 296-800-220 Housekeeping • 296-802 Employee Medical and Exposure Records.

27. Citation Guidelines (continued) Citation Review • Safe Place citation: • The proposed citation shall be reviewed by: • DOSH Compliance Manager; and • Occupational Nurse Consultant, prior to issuance.

28. Respiratory Protection Requirements High exposure risk: • Entering rooms with suspected or confirmed 2009 H1N1 influenza patients, • Attending to suspected or confirmed 2009 H1N1 influenza patients through close contact (within 6 feet), or • Transporting suspected or confirmed 2009 H1N1 influenza patients in enclosed vehicles. Very high exposure risk: Aerosol-generating procedures: • Bronchoscopy, • Sputum induction, • Endotracheal intubation and extubation, • Open suctioning of airways, • Cardiopulmonary resuscitation and • Autopsies

29. Respiratory Protection (continued) • respiratory protection must be at least as protective as a fit-tested disposable N95 filtering facepiece respirator. • Respiratory protection must be donned prior to entering a 2009 H1N1 influenza patient’s room.

30. Respiratory Protection Citations • 296-842-13005 – Failed to conduct an initial hazard evaluation • 296-842-13005 - Fails to select and provide appropriate respirator • 296-842-12005 – Failure to have a written program when respirators are required • 296-842-15005 – Failure to have initial or annual fit test • 296-842-17015 – Fails to ensure respirators are inspected

31. Respiratory Protection (continued) • Respirator Shortage: …extended use or re-use of N95 respirators is permitted, … • As long as the respirator maintains its structural and functional integrity and • the filter material is not physically damaged or soiled. • Employers must address in their respiratory protection program the circumstances under…considered to be contaminated and not available for extended use or re-use. • Guidance on reuse of respirators can be obtained from the CDC’s website at: www.cdc.gov/h1n1flu/guidelines_infection_control_qa.htm

32. Respiratory Protection (continued) Citations shall be issued for the failure to provide a respirator at least as effective as an N95 filtering facepieceunless the employer can establish all of the items listed: • There is a shortage of respirators that are at least as effective as an N95 respirators or better; • The employer made a good faith effort to obtain other alternative respirators such as N99, N100 or reusable elastomeric respirators; • The employer made an effort to monitor their supply of N95s and to prioritize their use according to CDC guidance; • Surgical masks and eye protection devices were provided as an interim measure to protect against splashes and large droplets and • Other measures were instituted to protect employees, for example, use of partitions or other engineering controls that might reduce the need for PPE or reducing exposure through cohorting patients.

33. Citation Guidelines (continued) • Other Personal Protective Equipment (PPE) Standards • Cite 296-800-16005 - Where an employer fails to conduct a hazard assessment to determine the need for PPE … to protect an employee’s eyes, as well as mouth and nose, from splashes, droplet sprays, and from autoinoculation of influenza virus from the fingers or hands. • Cite 296-800-16020 - When there is an established shortage of respirators and surgical masks are not provided and used. • Cite 296-800-16050 - Where an employer fails to provide or ensure the use of PPE that is needed to protect against splashes, droplet sprays and autoinoculation of influenza virus from the fingers and hands.

34. Safe Place • Safe Place Standard violations are based on the hazard of exposure to the 2009 H1N1 influenza. • CSHOs shall evaluate whether an employer has implemented engineering controls, for abatement of the hazard. • Potential engineering controls to be considered include: • AIIR rooms used for performance of aerosol-generating procedures are maintained under negative pressure; • Where AIIR rooms are not available, whether the employer has increased air changes and eliminated/minimized unfiltered recirculation of the room air; • Whether the employer has installed sneeze guards, windows at clerical intake areas or other barriers between workers and the general public (if feasible) to prevent transmission of the 2009 H1N1 influenza.

35. Safe Place (continued) • Administrative controls: • Ensuring that unprotected healthcare personnel are not allowed in rooms where an aerosol-generating procedure has been conducted unless the employer establishes that potentially infectious particles have been removed or minimized; • Screening and limiting access of sick visitors; implementing a system for expeditious triage, isolation and/or cohorting of suspected pandemic patients. • Encouraging employees at high to very high occupational exposure risk to get the 2009 H1N1 influenza vaccination and provide it at no cost. • Offering early treatment with antiviral medications after unprotected exposure.

36. Citation Guidelines (continued) • Other DOSH Standards Commonly Associated with Healthcare Employers • Bloodborne Pathogens. Compliance is required as per296-823. • Sanitation. Surfaces potentially contaminated with 2009 H1N1 influenza virus should be decontaminated pursuant to 296-800-22005. • Specification for accident prevention signs and tags. Warning signs shall be posted outside the entrance of isolation or treatment rooms in accordance with 296-800-110459(2) A description of the necessary precautions (e.g., “respiratory protection must be donned before entering”) should be included in the warning.

37. WIN Tracking • Please use the Drop-down box to code inspections with: H1N1

38. Resources Online • Worker & Employer Guidance for responding to H1N1 Flu Links to Other Resources: • DOH.wa.gov • Flu.gov • HHS/CDC - H1N1 Flu • WHO - Pandemic (H1N1) • OSHA's Pandemic Influenza Directive CPL 02-02-075 • NIOSH - H1N1 • CDC.gov

39. Questions John Furman, ONC (360-902-5666 or furk235@lni.wa.gov) may be contacted with any questions