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2009 H1N1 Influenza DOSH Directive 11.70

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. .

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2009 H1N1 Influenza DOSH Directive 11.70

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    1. 2009 H1N1 Influenza DOSH Directive 11.70 CSHOs should review DOSH Directive 11.70 prior to reviewing this training http://www.lni.wa.gov/Safety/Topics/AtoZ/H1N1/default.asp CSHOs should review DOSH Directive 11.70 prior to reviewing this training http://www.lni.wa.gov/Safety/Topics/AtoZ/H1N1/default.asp

    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. According to the Centers for Disease Control and Prevention (CDC), a part of the U.S. Department of Health and Human Services, and the primary federal public health agency, there are three types of influenza viruses: types A, B and C. While both Influenza A and B viruses can cause seasonal influenza, only type A influenza viruses have caused pandemics. Novel influenza strains emerge from time to time. Over the past few years, a number of different subtypes of influenza A viruses have emerged including the avian influenza A H5N1 virus which caused widespread human infection and sparked increasing concerns regarding the threat of a possible influenza pandemic. The CDC has acknowledged that during the early stages of any influenza pandemic, much is unknown about the characteristics of the pandemic influenza virus except that people will have little or no immunity to the new strain. Previous influenza pandemics have occurred in two or three waves of 6-8 weeks duration and spanned a 12-18 month period. After this period, the population will have built up immunity to the virus, either naturally or through vaccination. In May 2006, the Presidents Homeland Security Council released the National Strategy for Pandemic Influenza Implementation Plan (Strategy) to aid in the U.S. pandemic influenza preparation efforts (www.flu.gov/professional/federal/pandemic-influenza-implementation.pdf). The potential impact on the healthcare system (i.e., impact on medical resources and personnel) was one of the many areas of focus identified for preparedness planning. The Strategy gave Federal Agencies with public health responsibilities the duty of developing recommendations and strategies to guide the general public and employers in preparing to address the pandemic influenza outbreaks. During a pandemic, the Secretary of Health and Human Services is responsible for the overall coordination of the public health and medical emergency response, including provision of guidance on infection control and treatment strategies, and ongoing epidemiologic assessment, modeling of the outbreak, and research into the influenza virus, countermeasures, and rapid diagnostics. The Strategy also instructed state, local governments and the private sector, including employers having workers expected to require protection for job-related exposures, to initiate planning for pandemic influenza outbreaks. The Strategy recognizes that employers in hospitals and other acute care facilities are recognized as having unique challenges regarding pandemic preparedness and should have already developed plans to address issues such as: surge capacity, continuation of patient care, occupational health, and other administrative issues which are expected to arise during a pandemic outbreak. Based on the guidance from the Strategy, U.S. pandemic response measures, including community public health and workplace protections would be implemented. At the onset of a pandemic influenza, the knowledge concerning the severity and transmissibility of the virus may be limited and enhanced protection measures may be necessary. As the 2009 H1N1 influenza virus evolves and additional information become available, protective measures may need to be modified based on the updated information from the CDC, state and local government. Therefore, employers may need to adjust their 2009 H1N1 influenza virus plans as new information becomes known. According to the Centers for Disease Control and Prevention (CDC), a part of the U.S. Department of Health and Human Services, and the primary federal public health agency, there are three types of influenza viruses: types A, B and C. While both Influenza A and B viruses can cause seasonal influenza, only type A influenza viruses have caused pandemics. Novel influenza strains emerge from time to time. Over the past few years, a number of different subtypes of influenza A viruses have emerged including the avian influenza A H5N1 virus which caused widespread human infection and sparked increasing concerns regarding the threat of a possible influenza pandemic. The CDC has acknowledged that during the early stages of any influenza pandemic, much is unknown about the characteristics of the pandemic influenza virus except that people will have little or no immunity to the new strain. Previous influenza pandemics have occurred in two or three waves of 6-8 weeks duration and spanned a 12-18 month period. After this period, the population will have built up immunity to the virus, either naturally or through vaccination. In May 2006, the Presidents Homeland Security Council released the National Strategy for Pandemic Influenza Implementation Plan (Strategy) to aid in the U.S. pandemic influenza preparation efforts (www.flu.gov/professional/federal/pandemic-influenza-implementation.pdf). The potential impact on the healthcare system (i.e., impact on medical resources and personnel) was one of the many areas of focus identified for preparedness planning. The Strategy gave Federal Agencies with public health responsibilities the duty of developing recommendations and strategies to guide the general public and employers in preparing to address the pandemic influenza outbreaks. During a pandemic, the Secretary of Health and Human Services is responsible for the overall coordination of the public health and medical emergency response, including provision of guidance on infection control and treatment strategies, and ongoing epidemiologic assessment, modeling of the outbreak, and research into the influenza virus, countermeasures, and rapid diagnostics. The Strategy also instructed state, local governments and the private sector, including employers having workers expected to require protection for job-related exposures, to initiate planning for pandemic influenza outbreaks. The Strategy recognizes that employers in hospitals and other acute care facilities are recognized as having unique challenges regarding pandemic preparedness and should have already developed plans to address issues such as: surge capacity, continuation of patient care, occupational health, and other administrative issues which are expected to arise during a pandemic outbreak. Based on the guidance from the Strategy, U.S. pandemic response measures, including community public health and workplace protections would be implemented. At the onset of a pandemic influenza, the knowledge concerning the severity and transmissibility of the virus may be limited and enhanced protection measures may be necessary. As the 2009 H1N1 influenza virus evolves and additional information become available, protective measures may need to be modified based on the updated information from the CDC, state and local government. Therefore, employers may need to adjust their 2009 H1N1 influenza virus plans as new information becomes known.

    3. State Plan Policy States with OSHA-approved State Plans must adopt OSHAs enforcement policies or have their own enforcement policies that must be at least as effective as OSHAs. DOSH has elected to adopt its own Directive closely following OSHAs. 3 The Department of Labor through the Occupational Safety and Health Administration (OSHA) is primarily responsible for protecting the health and safety of workers, including communication of information related to 2009 H1N1 influenza to workers and employers. Public health agencies have developed recommendations to assist employers in preparing their workplaces to minimize transmission of a pandemic virus. OSHA adopted CPL 02-02-072, Enforcement Procedures for Very High to High Occupational Exposure Risk to 2009 H1N1 Influenza. A worker's risk of occupational exposure during an influenza pandemic may vary from very high to high, medium, or lower risk. The category of risk depends in part on whether or not job tasks and activities require close contact (within 6 feet) with patients with suspected or diagnosed 2009 H1N1 influenza or whether they are required to have either repeated or extended close contact with others (e.g., patients, coworkers, the general public, etc.). Some healthcare workers are considered to be at high to very high exposure risk based upon the nature of the tasks or activities they perform (e.g., those performing aerosol-generating procedures. DOSH Adopted DOSH Directive 11.70, Enforcement Procedures for Very High to High Occupational Exposure Risk to 2009 H1N1 Influenza, on December 23, 2009. The Directive is based on CPL 02-02-075 and current CDC guidance. The Directive establishes uniform procedures when conducting inspections to identify and minimize or eliminate high to very high risk occupational exposures in healthcare settings, including; laboratories, emergency medical services, and clinical areas within non-medical settings such as schools and correctional facilities. Directive 11.70 is effective immediately. DOSH Central office has been working with various agencies (e.g. DOH. DOC, OSPI) and associations (e.g. Washington State Hospital Association, Washington State Dental Association) to inform affected employers and stakeholders. On October 14, 2009 the Centers for Disease Control and Prevention (CDC) Guidelines, Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel was published. The CDC Guidelines recommends protective measures during 2009 H1N1 influenza waves when healthcare workers are performing tasks or activities where they will be expected to have close contact (within 6 feet) with suspected or confirmed 2009 H1N1 influenza patients. This Instruction, along with other CDC instructions regarding specific settings, e.g. schools, provides DOSHs field staff with additional guidance to address the hazard and the control measures associated with occupational exposure to the 2009 H1N1 Influenza. The Department of Labor through the Occupational Safety and Health Administration (OSHA) is primarily responsible for protecting the health and safety of workers, including communication of information related to 2009 H1N1 influenza to workers and employers. Public health agencies have developed recommendations to assist employers in preparing their workplaces to minimize transmission of a pandemic virus. OSHA adopted CPL 02-02-072, Enforcement Procedures for Very High to High Occupational Exposure Risk to 2009 H1N1 Influenza. A worker's risk of occupational exposure during an influenza pandemic may vary from very high to high, medium, or lower risk. The category of risk depends in part on whether or not job tasks and activities require close contact (within 6 feet) with patients with suspected or diagnosed 2009 H1N1 influenza or whether they are required to have either repeated or extended close contact with others (e.g., patients, coworkers, the general public, etc.). Some healthcare workers are considered to be at high to very high exposure risk based upon the nature of the tasks or activities they perform (e.g., those performing aerosol-generating procedures. DOSH Adopted DOSH Directive 11.70, Enforcement Procedures for Very High to High Occupational Exposure Risk to 2009 H1N1 Influenza, on December 23, 2009. The Directive is based on CPL 02-02-075 and current CDC guidance. The Directive establishes uniform procedures when conducting inspections to identify and minimize or eliminate high to very high risk occupational exposures in healthcare settings, including; laboratories, emergency medical services, and clinical areas within non-medical settings such as schools and correctional facilities. Directive 11.70 is effective immediately. DOSH Central office has been working with various agencies (e.g. DOH. DOC, OSPI) and associations (e.g. Washington State Hospital Association, Washington State Dental Association) to inform affected employers and stakeholders. On October 14, 2009 the Centers for Disease Control and Prevention (CDC) Guidelines, Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel was published. The CDC Guidelines recommends protective measures during 2009 H1N1 influenza waves when healthcare workers are performing tasks or activities where they will be expected to have close contact (within 6 feet) with suspected or confirmed 2009 H1N1 influenza patients. This Instruction, along with other CDC instructions regarding specific settings, e.g. schools, provides DOSHs field staff with additional guidance to address the hazard and the control measures associated with occupational exposure to the 2009 H1N1 Influenza.

    4. Publications Referenced 4 Additional references: 1. OSHA, Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers, OSHA Publication 3328, 2007. www.osha.gov/Publications/3328-05-2007-English.html 2. OSHA, Guidance on Preparing Workplaces for an Influenza Pandemic, OSHA Publication 3327, 2007. www.osha.gov/Publications/influenza_pandemic.html 3. Homeland Security Council, National Strategy for Pandemic Influenza Implementation Plan, May 2006. www.flu.gov/professional/federal/pandemic-influenza-implementation.pdf 4. Institute of Medicine, Preparing for an Influenza Pandemic Personal Protective Equipment for Healthcare Workers, 2007. Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers - Institute of Medicine 5. CDC, Interim Recommendation for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission, May 27, 2009. 6. CDC, Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic, October 2006. 7. CDC, Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel, October 14, 2009. www.cdc.gov/h1n1flu/guidelines_infection_control_htm. 8. CDC, Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season. October 16, 2009. www.cdc.gov/h1n1flu/recommendations.htm. 9. CDC, Guidance for Businesses and Employers to Plan and Respond to 2009-2010 Influenza Season, August 19, 2009. www.cdc.gov/h1n1flu/business/guidance/ 10. HHS, 2005 Pandemic Influenza Plan, Supplement 5. U.S. Department of Health and Human Services. Accessed on June 22, 2009. www.hhs.gov/pandemicflu/plan/sup5.html. 11. CDC, Community Strategy for Pandemic Influenza Mitigation, Feb. 2007 www.pandemicflu.gov/plan/community/commitigation.html 12. CDC, Hospital Influenza Pandemic Checklist www.pandemicflu.gov/plan/healthcare/hospitalchecklist.html 13. CDC, Hospital Planning webpage: www.pandemicflu.gov/plan/healthcare/index.html 14. Updated information from the federal government: www.pandemicflu.gov 15. Emergency Medical Services and Non-Emergent (Medical) Transport Organizations Pandemic Planning Checklist www.pandemicflu.gov/plan/healthcare/emgncymedical.html 16. IOM, Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A, September 3, 2009. www.iom.edu/Reports/2009/RespProtH1N1.aspx 17. World Health Organization (WHO) webpage. www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html Additional references: 1. OSHA, Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers, OSHA Publication 3328, 2007. www.osha.gov/Publications/3328-05-2007-English.html 2. OSHA, Guidance on Preparing Workplaces for an Influenza Pandemic, OSHA Publication 3327, 2007. www.osha.gov/Publications/influenza_pandemic.html 3. Homeland Security Council, National Strategy for Pandemic Influenza Implementation Plan, May 2006. www.flu.gov/professional/federal/pandemic-influenza-implementation.pdf 4. Institute of Medicine, Preparing for an Influenza Pandemic Personal Protective Equipment for Healthcare Workers, 2007. Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers - Institute of Medicine 5. CDC, Interim Recommendation for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission, May 27, 2009. 6. CDC, Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Healthcare Settings during an Influenza Pandemic, October 2006. 7. CDC, Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel, October 14, 2009. www.cdc.gov/h1n1flu/guidelines_infection_control_htm. 8. CDC, Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season. October 16, 2009. www.cdc.gov/h1n1flu/recommendations.htm. 9. CDC, Guidance for Businesses and Employers to Plan and Respond to 2009-2010 Influenza Season, August 19, 2009. www.cdc.gov/h1n1flu/business/guidance/ 10. HHS, 2005 Pandemic Influenza Plan, Supplement 5. U.S. Department of Health and Human Services. Accessed on June 22, 2009. www.hhs.gov/pandemicflu/plan/sup5.html. 11. CDC, Community Strategy for Pandemic Influenza Mitigation, Feb. 2007 www.pandemicflu.gov/plan/community/commitigation.html 12. CDC, Hospital Influenza Pandemic Checklist www.pandemicflu.gov/plan/healthcare/hospitalchecklist.html 13. CDC, Hospital Planning webpage: www.pandemicflu.gov/plan/healthcare/index.html 14. Updated information from the federal government: www.pandemicflu.gov 15. Emergency Medical Services and Non-Emergent (Medical) Transport Organizations Pandemic Planning Checklist www.pandemicflu.gov/plan/healthcare/emgncymedical.html 16. IOM, Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A, September 3, 2009. www.iom.edu/Reports/2009/RespProtH1N1.aspx 17. World Health Organization (WHO) webpage. www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html

    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. Directive 11.70 establishes agency enforcement policies and provides instructions to ensure uniform inspection procedures when conducting inspections 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. The directive consolidates OSHA direction, and guidance provided by the CDC by emphasizing that successfully preventing transmission requires a comprehensive approach, beginning with pandemic planning that includes developing written plans that are flexible and adaptable should changes occur in the severity of illness or other aspects of 2009 H1N1 and seasonal influenza. The directive relies on application of the hierarchy of controls which ranks preventive interventions in the following order of preference: elimination of exposures, engineering controls, administrative controls, and personal protective equipment; and guidance on use of respiratory protection. A successful infection control program for pandemic influenza utilizes the same strategies implemented for any infectious agent, including facility and environmental controls (i.e., engineering controls), standard operating procedures (i.e., administrative controls), personal protective clothing and equipment, and safe work practices. These strategies form the basis of standard precautions and transmission-based precautions. Given that the exact transmission pattern or patterns will not be known until after the pandemic influenza virus emerges, transmission-based infection control strategies have been modified to include use or respiratory protection when providing services when within 6 feet of a suspect or diagnosed 2009 H1N1 influenza patient. Pandemic influenza plan checklists can be found here www.flu.gov/professional/checklists.html Directive 11.70 establishes agency enforcement policies and provides instructions to ensure uniform inspection procedures when conducting inspections 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. The directive consolidates OSHA direction, and guidance provided by the CDC by emphasizing that successfully preventing transmission requires a comprehensive approach, beginning with pandemic planning that includes developing written plans that are flexible and adaptable should changes occur in the severity of illness or other aspects of 2009 H1N1 and seasonal influenza. The directive relies on application of the hierarchy of controls which ranks preventive interventions in the following order of preference: elimination of exposures, engineering controls, administrative controls, and personal protective equipment; and guidance on use of respiratory protection. A successful infection control program for pandemic influenza utilizes the same strategies implemented for any infectious agent, including facility and environmental controls (i.e., engineering controls), standard operating procedures (i.e., administrative controls), personal protective clothing and equipment, and safe work practices. These strategies form the basis of standard precautions and transmission-based precautions. Given that the exact transmission pattern or patterns will not be known until after the pandemic influenza virus emerges, transmission-based infection control strategies have been modified to include use or respiratory protection when providing services when within 6 feet of a suspect or diagnosed 2009 H1N1 influenza patient. Pandemic influenza plan checklists can be found here www.flu.gov/professional/checklists.html

    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. Directive 11.70 applies DOSH-wide and applies uniquely to the 2009 H1N1 influenza virus and is not mean to establish new regulation for seasonal influenza. Inspections will be conducted in response to complaints and referrals regarding healthcare settings where employees have very high or high occupational exposure risk to 2009 H1N1 influenza. The Directive may be updated as new information becomes available. When inspecting healthcare settings that are likely to have very high or high risk employee exposure the CSHO must determine whether services have been provided to a suspect or diagnosed H1N1 influenza patient within the previous 6 months. If not, the inspection will generally be confined to an evaluation of the employers APP, and/or Pandemic Influenza Response Plan and related policies. Complaints and referrals related to non-healthcare settings or healthcare settings where employees only have medium or low exposure risk will be responded to via phone/fax. Non-healthcare employers may be provided with general business resources such as http://www.cdc.gov/h1n1flu/business/guidance/ and http://www.cdc.gov/H1N1flu/business/toolkit/pdf/Business_Toolkit.pdf Directive 11.70 applies DOSH-wide and applies uniquely to the 2009 H1N1 influenza virus and is not mean to establish new regulation for seasonal influenza. Inspections will be conducted in response to complaints and referrals regarding healthcare settings where employees have very high or high occupational exposure risk to 2009 H1N1 influenza. The Directive may be updated as new information becomes available. When inspecting healthcare settings that are likely to have very high or high risk employee exposure the CSHO must determine whether services have been provided to a suspect or diagnosed H1N1 influenza patient within the previous 6 months. If not, the inspection will generally be confined to an evaluation of the employers APP, and/or Pandemic Influenza Response Plan and related policies. Complaints and referrals related to non-healthcare settings or healthcare settings where employees only have medium or low exposure risk will be responded to via phone/fax. Non-healthcare employers may be provided with general business resources such as http://www.cdc.gov/h1n1flu/business/guidance/ and http://www.cdc.gov/H1N1flu/business/toolkit/pdf/Business_Toolkit.pdf

    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 7 Many non-healthcare settings (e.g. schools, correctional facilities, inpatient drug treatment facilities) also provide clinical services and pose special risks and considerations due to the nature of their unique environment. For example, inmates are in mandatory custody and options are limited for isolation and removal of ill persons from the environment. In addition, many inmates and workforce may have medical conditions that increase their risk of influenza-related complications. DOSH enforcement focus is on the high risk activities performed by healthcare staff in these settings general preventive measures, risk reduction of introduction of the virus into institutions, rapid detection of persons with novel influenza A (H1N1) infections, and management and isolation of identified cases will be assessed. Directive 11.70 applies to only clinical services within non-medical settings, e.g. the school health clinic. Non-medical staff may also be covered when working within clinical areas. In addition to the direction contained in Directive 11.70 reference applicable CDC guidelines for these settings, such as: http://www.cdc.gov/h1n1flu/guidance/correctional_facilities.htm http://www.cdc.gov/h1n1flu/schools/technicalreport.htm Contact the DOSH Occupational Nurse Consultant with any questions regarding these type settings. Many non-healthcare settings (e.g. schools, correctional facilities, inpatient drug treatment facilities) also provide clinical services and pose special risks and considerations due to the nature of their unique environment. For example, inmates are in mandatory custody and options are limited for isolation and removal of ill persons from the environment. In addition, many inmates and workforce may have medical conditions that increase their risk of influenza-related complications. DOSH enforcement focus is on the high risk activities performed by healthcare staff in these settings general preventive measures, risk reduction of introduction of the virus into institutions, rapid detection of persons with novel influenza A (H1N1) infections, and management and isolation of identified cases will be assessed. Directive 11.70 applies to only clinical services within non-medical settings, e.g. the school health clinic. Non-medical staff may also be covered when working within clinical areas. In addition to the direction contained in Directive 11.70 reference applicable CDC guidelines for these settings, such as: http://www.cdc.gov/h1n1flu/guidance/correctional_facilities.htm http://www.cdc.gov/h1n1flu/schools/technicalreport.htm Contact the DOSH Occupational Nurse Consultant with any questions regarding these type 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 8 Employee risks of occupational exposure to influenza during a pandemic may vary from very high to high, medium, or lower (caution) risk. The level of risk depends in part on whether or not jobs require close proximity to people potentially infected with the pandemic influenza virus, or whether they are required to have either repeated or extended contact with known or suspected sources of pandemic influenza virus such as coworkers, the general public, outpatients, school children or other such individuals or groups. Very High Exposure Risk: 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. Healthcare workers (for example, doctors, respiratory therapists, nurses, emergency responders, or dentists) performing aerosol-generating procedures on suspected or confirmed patients (such as, sputum inductions, endotracheal intubations and extubations, bronchoscopies, some dental procedures or invasive specimen collection). Healthcare workers present during performance of aerosol-generating procedures during autopsies (such as, medical examiners). High Exposure Risk: A job task or activity involving a high potential for exposure to suspected or confirmed 2009 H1N1 influenza virus. 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). Medium Exposure Risk: Employees with high-frequency contact with the general population (such as schools, high population density work environments, and some high volume retail). Low Exposure Risk: Employees who have minimal occupational contact with the general public and other coworkers (for example, office employees). Note: This directive does not apply to medium or lower risk occupational exposures. Examples of these categories of risk are provided for information purposes only Employee risks of occupational exposure to influenza during a pandemic may vary from very high to high, medium, or lower (caution) risk. The level of risk depends in part on whether or not jobs require close proximity to people potentially infected with the pandemic influenza virus, or whether they are required to have either repeated or extended contact with known or suspected sources of pandemic influenza virus such as coworkers, the general public, outpatients, school children or other such individuals or groups. Very High Exposure Risk: 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. Healthcare workers (for example, doctors, respiratory therapists, nurses, emergency responders, or dentists) performing aerosol-generating procedures on suspected or confirmed patients (such as, sputum inductions, endotracheal intubations and extubations, bronchoscopies, some dental procedures or invasive specimen collection). Healthcare workers present during performance of aerosol-generating procedures during autopsies (such as, medical examiners). High Exposure Risk: A job task or activity involving a high potential for exposure to suspected or confirmed 2009 H1N1 influenza virus. 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). Medium Exposure Risk: Employees with high-frequency contact with the general population (such as schools, high population density work environments, and some high volume retail). Low Exposure Risk: Employees who have minimal occupational contact with the general public and other coworkers (for example, office employees). Note: This directive does not apply to medium or lower risk occupational exposures. Examples of these categories of risk are provided for information purposes only

    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. 9 For the purposes Directive 11.70, healthcare personnel are defined as all persons whose occupational activities involve contact with patients or contaminated material in a healthcare, home healthcare, or clinical laboratory setting. Healthcare personnel are engaged in a range of occupations, many of which include patient contact even though they do not involve direct provision of patient care, such as dietary and housekeeping services. This guidance applies to healthcare personnel working in the following settings: acute care hospitals, nursing homes, skilled nursing facilities, physicians offices, urgent care centers, outpatient clinics, and home healthcare agencies. It also includes those working in clinical settings within non-healthcare institutions, such as school nurses or personnel staffing clinics in correctional facilities. The term healthcare personnel includes not only employees of the organization or agency, but also contractors, clinicians, and others who may have significant contact with with patients. If an investigation under this directive involves home healthcare employees, CSHOs shall conduct their inspection at the offices of the healthcare employer. Under no circumstances shall CSHOs visit private residences during the evidence gathering process. For the purposes Directive 11.70, healthcare personnel are defined as all persons whose occupational activities involve contact with patients or contaminated material in a healthcare, home healthcare, or clinical laboratory setting. Healthcare personnel are engaged in a range of occupations, many of which include patient contact even though they do not involve direct provision of patient care, such as dietary and housekeeping services. This guidance applies to healthcare personnel working in the following settings: acute care hospitals, nursing homes, skilled nursing facilities, physicians offices, urgent care centers, outpatient clinics, and home healthcare agencies. It also includes those working in clinical settings within non-healthcare institutions, such as school nurses or personnel staffing clinics in correctional facilities. The term healthcare personnel includes not only employees of the organization or agency, but also contractors, clinicians, and others who may have significant contact with with patients. If an investigation under this directive involves home healthcare employees, CSHOs shall conduct their inspection at the offices of the healthcare employer. Under no circumstances shall CSHOs visit private residences during the evidence gathering process.

    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. Patients may produce infectious respiratory aerosols when they cough, sneeze, or through the performance of aerosol-generating procedures that generate high airflow. Even though most respiratory droplets are too large to travel great distances studies have also shown that clouds of smaller infectious particles (>5 um) may created during the performance of aerosol generating procedures. The National Institutes of Medicine and CDC recognize the potential for aerosol transmission of 2009 H1N1 influenza. Employers must evaluate the exposure hazards associates with aerosol-generating procedures performed on suspect or diagnosed H1N1 influenza patients and select respiratory protection. The hazard assessment and respirator selection must be documented in the employers written respiratory protection program or related documents. Patients may produce infectious respiratory aerosols when they cough, sneeze, or through the performance of aerosol-generating procedures that generate high airflow. Even though most respiratory droplets are too large to travel great distances studies have also shown that clouds of smaller infectious particles (>5 um) may created during the performance of aerosol generating procedures. The National Institutes of Medicine and CDC recognize the potential for aerosol transmission of 2009 H1N1 influenza. Employers must evaluate the exposure hazards associates with aerosol-generating procedures performed on suspect or diagnosed H1N1 influenza patients and select respiratory protection. The hazard assessment and respirator selection must be documented in the employers written respiratory protection program or related documents.

    11. Aerosol-Generating Procedures The aerosol-generating procedures include: Bronchoscopy Sputum induction Endotracheal intubation and extubation Open suctioning of airways Cardiopulmonary resuscitation Autopsies 11 Some procedures performed on patients are more likely to generate higher concentrations of respiratory aerosols than coughing, sneezing, talking, or breathing, presenting healthcare personnel with an increased risk of exposure to infectious agents present in the aerosol. Although there are limited objective data available on disease transmission related to such aerosols, many authorities view the listed procedures as being very high exposure risk aerosol-generating procedures for which special precautions should be used: To reduce exposure risk, healthcare personnel should only perform these procedures on patients with suspected or confirmed influenza when medically necessary and limit the number of healthcare personnel in the room. These procedures should also be conducted in airborne infection isolation rooms , when available. Healthcare personnel must adhere to standard precautions and wear respiratory protection (N95 or higher) when conducting or are present during these activities. Unprotected healthcare personnel should not be allowed in a room where an aerosol-generating procedure has been conducted until sufficient time has elapsed to remove potentially infectious particles. More information on clearance rates is available here http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm Some procedures performed on patients are more likely to generate higher concentrations of respiratory aerosols than coughing, sneezing, talking, or breathing, presenting healthcare personnel with an increased risk of exposure to infectious agents present in the aerosol. Although there are limited objective data available on disease transmission related to such aerosols, many authorities view the listed procedures as being very high exposure risk aerosol-generating procedures for which special precautions should be used: To reduce exposure risk, healthcare personnel should only perform these procedures on patients with suspected or confirmed influenza when medically necessary and limit the number of healthcare personnel in the room. These procedures should also be conducted in airborne infection isolation rooms , when available. Healthcare personnel must adhere to standard precautions and wear respiratory protection (N95 or higher) when conducting or are present during these activities. Unprotected healthcare personnel should not be allowed in a room where an aerosol-generating procedure has been conducted until sufficient time has elapsed to remove potentially infectious particles. More information on clearance rates is available here http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm

    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). 12 Studies on influenza transmission show that airborne (inhalation) transmission is one of the potential routes of transmission. It does not appear that the 2009 H1N1 influenza virus is transmitted by the aerosol route over long distances (e.g. through ventilation systems) therefore routine placement in airborne infection isolation rooms is not indicated. However, respiratory protection is required when providing direct services (within 6 feet, or in a common size patient room) with a suspect or diagnosed 2008 H1N1 influenza patient. Incidental exposure, e.g. passing within 6 feet of a suspect or diagnosed H1N1 influenza patient in the hall when not providing direct care, would not result in a citation. All respiratory secretions and bodily fluids, including diarrheal stools, of patients with 2009 H1N1 influenza are considered to be potentially infectious. Studies on influenza transmission show that airborne (inhalation) transmission is one of the potential routes of transmission. It does not appear that the 2009 H1N1 influenza virus is transmitted by the aerosol route over long distances (e.g. through ventilation systems) therefore routine placement in airborne infection isolation rooms is not indicated. However, respiratory protection is required when providing direct services (within 6 feet, or in a common size patient room) with a suspect or diagnosed 2008 H1N1 influenza patient. Incidental exposure, e.g. passing within 6 feet of a suspect or diagnosed H1N1 influenza patient in the hall when not providing direct care, would not result in a citation. All respiratory secretions and bodily fluids, including diarrheal stools, of patients with 2009 H1N1 influenza are considered to be potentially infectious.

    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. Elimination actions may include: Entry screening of visitors Restricting access to the facility to those older than 12 years of age Limiting visitors to patients in isolation Limiting healthcare workers entering isolation rooms Utilizing written policies regarding transport and movement of patients Utilizing written policies regarding exclusion of exposed and ill health care workers Postponing elective visits and procedures for patients with suspected or diagnosed influenza until they are no longer infectious Minimizing outpatient and emergency department visits for patients with mild influenza-like illness who do not have risk factors for complications. Elimination actions may include: Entry screening of visitors Restricting access to the facility to those older than 12 years of age Limiting visitors to patients in isolation Limiting healthcare workers entering isolation rooms Utilizing written policies regarding transport and movement of patients Utilizing written policies regarding exclusion of exposed and ill health care workers Postponing elective visits and procedures for patients with suspected or diagnosed influenza until they are no longer infectious Minimizing outpatient and emergency department visits for patients with mild influenza-like illness who do not have risk factors for complications.

    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 14 Engineering controls may include: Installing partitions (e.g., transparent panels/windows/desk enclosures) in triage areas as physical barriers to shield staff from respiratory droplets Using local exhaust ventilation (e.g., hoods, tents, or booths) for aerosol-generating procedures Using hoods for the performance of laboratory manipulations that generate aerosols Using ventilation controls in ambulances Installing hands-free soap and water dispensers, and receptacles for garbage and linens to minimize environmental contact Conducting aerosol-generating procedures in an airborne infection isolation room (AIIR) to prevent spread of aerosols to other part sof the faciltiy Using closed suctioning systems for suctioning of intubated patients Ensuring effective general ventilation Implementing thorough environmental cleaning protocols Providing separate waiting areas for patients with influenza like illness. Engineering controls may include: Installing partitions (e.g., transparent panels/windows/desk enclosures) in triage areas as physical barriers to shield staff from respiratory droplets Using local exhaust ventilation (e.g., hoods, tents, or booths) for aerosol-generating procedures Using hoods for the performance of laboratory manipulations that generate aerosols Using ventilation controls in ambulances Installing hands-free soap and water dispensers, and receptacles for garbage and linens to minimize environmental contact Conducting aerosol-generating procedures in an airborne infection isolation room (AIIR) to prevent spread of aerosols to other part sof the faciltiy Using closed suctioning systems for suctioning of intubated patients Ensuring effective general ventilation Implementing thorough environmental cleaning protocols Providing separate waiting areas for patients with influenza like illness.

    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 15 Administrative controls may include: Vaccination of healthcare workers against 2009 H1N1 influenza Enforcement of respiratory hygiene and cough etiquette by staff and visitors; and provision of adequate supplies to allow good compliance http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm Placing surgical style masks on patients with respiratory symptoms upon entry and during transport within the facility Identifying and isolating patients with known or suspected influenza infections Setting up triage stations, managing patient flow, and assigning dedicated staff to minimize the number of healthcare workers exposed to those with suspected or diagnosed 2009 H1N12 influenza Screening healthcare workers and visitors for signs and symptoms of infection at clinic or hospital entrances or badging stations and responding appropriately Adhering to isolation precautions Limiting the number of persons present in patient rooms and during aerosol-generating procedures Arranging seating to allow 6 feet between chairs or between families when possible Establishing protocols for cleaning of frequently touched surfaces throughout the facility (elevator buttons, hand rails, etc.) Locating signage in appropriate language and at appropriate reading level in areas to alert staff and visitors of the nee for specific precautions Limiting transport of 2009 H1N1 influenza patients to that which is medically necessary and minimizing delays and waiting times during transport. Administrative controls may include: Vaccination of healthcare workers against 2009 H1N1 influenza Enforcement of respiratory hygiene and cough etiquette by staff and visitors; and provision of adequate supplies to allow good compliance http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm Placing surgical style masks on patients with respiratory symptoms upon entry and during transport within the facility Identifying and isolating patients with known or suspected influenza infections Setting up triage stations, managing patient flow, and assigning dedicated staff to minimize the number of healthcare workers exposed to those with suspected or diagnosed 2009 H1N12 influenza Screening healthcare workers and visitors for signs and symptoms of infection at clinic or hospital entrances or badging stations and responding appropriately Adhering to isolation precautions Limiting the number of persons present in patient rooms and during aerosol-generating procedures Arranging seating to allow 6 feet between chairs or between families when possible Establishing protocols for cleaning of frequently touched surfaces throughout the facility (elevator buttons, hand rails, etc.) Locating signage in appropriate language and at appropriate reading level in areas to alert staff and visitors of the nee for specific precautions Limiting transport of 2009 H1N1 influenza patients to that which is medically necessary and minimizing delays and waiting times during transport.

    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. 16 The evaluation of occupational exposure to the 2009 H1N1 influenza virus shall be conducted in response to employee complaints, referrals, and related employee hospitalizations and deaths Code all 2009 H1N1 influenza inspections by selecting H1N1 in the Emphasis Information Box. All inspections will be reviewed by the statewide DOSH Compliance Manager and Occupational Nurse Consultant prior to the closing conference. When responding via phone/fax, employers may be provided appropriate materials available through the: Department of Health http://www.doh.wa.gov/h1n1/h1n1_business.htm OSHA http://www.osha.gov/h1n1/ and http://www.osha.gov/dsg/topics/pandemicflu/index.html CDC http://www.cdc.gov/h1n1flu/ The evaluation of occupational exposure to the 2009 H1N1 influenza virus shall be conducted in response to employee complaints, referrals, and related employee hospitalizations and deaths Code all 2009 H1N1 influenza inspections by selecting H1N1 in the Emphasis Information Box. All inspections will be reviewed by the statewide DOSH Compliance Manager and Occupational Nurse Consultant prior to the closing conference. When responding via phone/fax, employers may be provided appropriate materials available through the: Department of Health http://www.doh.wa.gov/h1n1/h1n1_business.htm OSHA http://www.osha.gov/h1n1/ and http://www.osha.gov/dsg/topics/pandemicflu/index.html CDC http://www.cdc.gov/h1n1flu/

    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. 17 Healthcare facilities should have written pandemic influenza plans and policies anticipating widespread transmission of 2009 H1N1 influenza in communities. CDC, with input from other federal partners, has developed checklists to help healthcare facilities in their planning and preparedness for pandemic influenza. OSHA has also developed detailed guidance for healthcare settings. Healthcare facilities should also check with state and local health departments for local guidance. During the planning process, facilities should review their work areas and job tasks to identify workers who will routinely be in close contact with influenza patients so that preventive strategies can be targeted and exposure that is not essential can be limited. Facilities also should consider their own unique circumstances and needs that may not be addressed in guidance documents. Planning committees can facilitate this process. Strong sustained management commitment and active worker participation in a comprehensive, coordinated prevention program are extremely important in promoting implementation of, and adherence to, prevention recommendations. Healthcare facilities generally have internal infection control and employee health and safety programs that may be administered by a team or individual. Upon entry, CSHOs shall ask to speak to the infection control director, safety director, and/or the health professional responsible for occupational health hazard control. Other individuals responsible for providing records pertinent to the inspection should also be included in the opening conference or interviewed early in the inspection (e.g., facility administrator, training director, facilities engineer, director of nursing, human resources, etc.). Healthcare facilities should have written pandemic influenza plans and policies anticipating widespread transmission of 2009 H1N1 influenza in communities. CDC, with input from other federal partners, has developed checklists to help healthcare facilities in their planning and preparedness for pandemic influenza. OSHA has also developed detailed guidance for healthcare settings. Healthcare facilities should also check with state and local health departments for local guidance. During the planning process, facilities should review their work areas and job tasks to identify workers who will routinely be in close contact with influenza patients so that preventive strategies can be targeted and exposure that is not essential can be limited. Facilities also should consider their own unique circumstances and needs that may not be addressed in guidance documents. Planning committees can facilitate this process. Strong sustained management commitment and active worker participation in a comprehensive, coordinated prevention program are extremely important in promoting implementation of, and adherence to, prevention recommendations. Healthcare facilities generally have internal infection control and employee health and safety programs that may be administered by a team or individual. Upon entry, CSHOs shall ask to speak to the infection control director, safety director, and/or the health professional responsible for occupational health hazard control. Other individuals responsible for providing records pertinent to the inspection should also be included in the opening conference or interviewed early in the inspection (e.g., facility administrator, training director, facilities engineer, director of nursing, human resources, etc.).

    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 employers 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. 18 For purposes of DOSH injury and illness recordkeeping, illnesses due to the 2009 H1N1 influenza is not considered a common cold or seasonal flu. The work-relatedness exception for the common cold or flu under WAC 297-27 does not apply to these cases. Employers are responsible for recording cases of 2009 H1N1 illness if all of the following requirements are met: (1) the case is a confirmed case of 2009 H1N1 illness as defined by CDC; (2) the case is; and (3) the case involves one or more of the recording criteria (e.g., medical treatment, days away from work). DOH Emergency Rules 246-101-101 and 246-101-301 requires 2009 H1N1 influenza hospitalizations, deaths, and laboratory confirmed cases be reported to DOH. All reports should be recorded and made available upon request. For purposes of DOSH injury and illness recordkeeping, illnesses due to the 2009 H1N1 influenza is not considered a common cold or seasonal flu. The work-relatedness exception for the common cold or flu under WAC 297-27 does not apply to these cases. Employers are responsible for recording cases of 2009 H1N1 illness if all of the following requirements are met: (1) the case is a confirmed case of 2009 H1N1 illness as defined by CDC; (2) the case is; and (3) the case involves one or more of the recording criteria (e.g., medical treatment, days away from work). DOH Emergency Rules 246-101-101 and 246-101-301 requires 2009 H1N1 influenza hospitalizations, deaths, and laboratory confirmed cases be reported to DOH. All reports should be recorded and made available upon request.

    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 documentationunder no circumstances shall photographing or videotaping of patients be done, and CSHOs must take all necessary precautions to assure and protect patient confidentiality. 19 The CSHO shall verify implementation of the employer's pandemic influenza control plans through employee interviews and direct observation where feasible. After review of the facility plans for worker influenza protection, employee interviews combined with an inspection of appropriate areas of the facility, shall be used to determine compliance 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. However, under no circumstances shall photographing or videotaping of patients be done, and CSHOs must take all necessary precautions to assure and protect patient confidentiality. CSHOs shall interview those employees who work in areas where high or very high 2009 H1N1 influenza exposure risks would be expected (e.g., emergency rooms, treatment rooms, areas used for isolation, areas where sputum induction, bronchoscopy, airway suctioning, etc. are performed). Interviews shall not take place in a room or area where a high-hazard procedure such as bronchoscopy, sputum induction, endotrachael intubation and extubation, open suctioning of airways, cardiopulmonary resuscitation, or autopsies is being conducted. Where the CSHO determines that access to patient health records is necessary the CSHO shall contact the DOSH Occupational Nurse Consultant before proceeding. The CSHO shall verify implementation of the employer's pandemic influenza control plans through employee interviews and direct observation where feasible. After review of the facility plans for worker influenza protection, employee interviews combined with an inspection of appropriate areas of the facility, shall be used to determine compliance 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. However, under no circumstances shall photographing or videotaping of patients be done, and CSHOs must take all necessary precautions to assure and protect patient confidentiality. CSHOs shall interview those employees who work in areas where high or very high 2009 H1N1 influenza exposure risks would be expected (e.g., emergency rooms, treatment rooms, areas used for isolation, areas where sputum induction, bronchoscopy, airway suctioning, etc. are performed). Interviews shall not take place in a room or area where a high-hazard procedure such as bronchoscopy, sputum induction, endotrachael intubation and extubation, open suctioning of airways, cardiopulmonary resuscitation, or autopsies is being conducted. Where the CSHO determines that access to patient health records is necessary the CSHO shall contact the DOSH Occupational Nurse Consultant before proceeding.

    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 20 Region supervisors and managers shall ensure that CSHOs performing 2009 H1N1 influenza-related inspections are familiar with the most recent CDC Interim Guidelines and DOSHs Directive. CSHOs shall use judgment and exercise caution when engaging in inspection-related activities that may involve their potential exposure to 2009 H1N1 influenza. CSHOs shall inquire as to potential workplace hazards and adequacy of work practices through worker interviews, and inspect facilities in a manner that minimizes or prevents exposure (for example, view employee work tasks through an observation window). CSHOs shall avoid potential exposure to suspected or confirmed 2009 H1N1 patients in isolation areas or very high hazard procedure rooms (e.g., bronchoscopy suites). 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 (to allow for proper clearance of the 2009 H1N1 influenza virus) 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 who have suspect or diagnosed 2009 H1N1 influenza illness.. It is not expected that CSHOs will perform tasks requiring the use of PPE while conducting inspections related to the H1N1 influenza. However, they must ask employers if there are any facility-imposed PPE requirements that will need to be adhered to during the inspection. Under circumstances where CSHOs need to test ventilation or air flow of a room (e.g., aerosol-generating procedure rooms), 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 or antiseptic towelettes if handwashing facilities are not immediately available. CSHOs who conduct 2009 H1N1 influenza inspections are encouraged to get the seasonal and/or 2009 H1N1 influenza vaccinations. See ISH policies 8.01, 8.11, 8.15, and 8.22 http://admin-services.inside.lni.wa.gov/policies/default.htm Region supervisors and managers shall ensure that CSHOs performing 2009 H1N1 influenza-related inspections are familiar with the most recent CDC Interim Guidelines and DOSHs Directive. CSHOs shall use judgment and exercise caution when engaging in inspection-related activities that may involve their potential exposure to 2009 H1N1 influenza. CSHOs shall inquire as to potential workplace hazards and adequacy of work practices through worker interviews, and inspect facilities in a manner that minimizes or prevents exposure (for example, view employee work tasks through an observation window). CSHOs shall avoid potential exposure to suspected or confirmed 2009 H1N1 patients in isolation areas or very high hazard procedure rooms (e.g., bronchoscopy suites). 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 (to allow for proper clearance of the 2009 H1N1 influenza virus) 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 who have suspect or diagnosed 2009 H1N1 influenza illness.. It is not expected that CSHOs will perform tasks requiring the use of PPE while conducting inspections related to the H1N1 influenza. However, they must ask employers if there are any facility-imposed PPE requirements that will need to be adhered to during the inspection. Under circumstances where CSHOs need to test ventilation or air flow of a room (e.g., aerosol-generating procedure rooms), 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 or antiseptic towelettes if handwashing facilities are not immediately available. CSHOs who conduct 2009 H1N1 influenza inspections are encouraged to get the seasonal and/or 2009 H1N1 influenza vaccinations. See ISH policies 8.01, 8.11, 8.15, and 8.22 http://admin-services.inside.lni.wa.gov/policies/default.htm

    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 . 21 Information regarding airborne inflection isolation rooms can be found here http://www.cdc.gov/tb/publications/guidelines/infectioncontrol.htm http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm Information regarding airborne inflection isolation rooms can be found here http://www.cdc.gov/tb/publications/guidelines/infectioncontrol.htm http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

    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. 22 CSHOs shall use judgment and exercise caution when engaging in inspection-related activities that may involve their potential exposure to 2009 H1N1 influenza. CSHOs shall inquire as to potential workplace hazards and adequacy of work practices through worker interviews, and inspect facilities in a manner that minimizes or prevents exposure (for example, view employee work tasks through an observation window) CSHOs shall avoid potential exposure to suspected or confirmed 2009 H1N1 patients in isolation areas or very high hazard procedure rooms (e.g., bronchoscopy suites). 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 (to allow for proper clearance of the 2009 H1N1 influenza virus) 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. It is not expected that CSHOs will perform tasks requiring the use of PPE while conducting inspections related to the H1N1 influenza. However, they must ask employers if there are any facility-imposed PPE requirements that will need to be adhered to during the inspection. Under circumstances where CSHOs need to test ventilation or air flow of a room (e.g., aerosol-generating procedure rooms), 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 or antiseptic towelettes if handwashing facilities are not immediately available. See ISH policies 8.01, 8.11, 8.15, and 8.22 http://admin-services.inside.lni.wa.gov/policies/default.htm CSHOs shall use judgment and exercise caution when engaging in inspection-related activities that may involve their potential exposure to 2009 H1N1 influenza. CSHOs shall inquire as to potential workplace hazards and adequacy of work practices through worker interviews, and inspect facilities in a manner that minimizes or prevents exposure (for example, view employee work tasks through an observation window) CSHOs shall avoid potential exposure to suspected or confirmed 2009 H1N1 patients in isolation areas or very high hazard procedure rooms (e.g., bronchoscopy suites). 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 (to allow for proper clearance of the 2009 H1N1 influenza virus) 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. It is not expected that CSHOs will perform tasks requiring the use of PPE while conducting inspections related to the H1N1 influenza. However, they must ask employers if there are any facility-imposed PPE requirements that will need to be adhered to during the inspection. Under circumstances where CSHOs need to test ventilation or air flow of a room (e.g., aerosol-generating procedure rooms), 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 or antiseptic towelettes if handwashing facilities are not immediately available. See ISH policies 8.01, 8.11, 8.15, and 8.22 http://admin-services.inside.lni.wa.gov/policies/default.htm

    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. 23 HIPAA permits disclosure of employee medical information without authorization, consent, or opportunity to agree or object, re: 45 CFR 164.512 (d) Standard: uses and disclosures for health oversight activities. DOSH Directive 11.70 constitutes medical surveillance requirements under WAC 296-802-50010. Contact the DOSH Occupational Nurse Consultant if the employer objects to providing requesting employee medical records. HIPAA permits disclosure of employee medical information without authorization, consent, or opportunity to agree or object, re: 45 CFR 164.512 (d) Standard: uses and disclosures for health oversight activities. DOSH Directive 11.70 constitutes medical surveillance requirements under WAC 296-802-50010. Contact the DOSH Occupational Nurse Consultant if the employer objects to providing requesting employee medical records.

    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). 24 For purposes of OSHA injury and illness recordkeeping, illnesses due to the 2009 H1N1 influenza is not considered a common cold or seasonal flu. The work-relatedness exception for the common cold or flu at WAC 296-27-01103 does not apply to these cases. CSHOs shall confirm OSHA 300 log entries with Occupational Health Services records. Occupational Health Services may be provided in-house or through a contracted provider. For purposes of OSHA injury and illness recordkeeping, illnesses due to the 2009 H1N1 influenza is not considered a common cold or seasonal flu. The work-relatedness exception for the common cold or flu at WAC 296-27-01103 does not apply to these cases. CSHOs shall confirm OSHA 300 log entries with Occupational Health Services records. Occupational Health Services may be provided in-house or through a contracted provider.

    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) 25

    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. 26

    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. 27 An employer's general obligation to provide a "safe and healthful workplace" under the Washington Industrial Safety and Health Act (WISHA) includes exposure to harmful diseases. Due to the relatively recent recognition of the potential occupational hazards related to the 2009 H1N1 influenza virus , the potential lack of employer knowledge on this issue, and the recent adoption of DOSH Direction ion this issue, all 2009 H1N1 influenza related inspections shall be reviewed by the statewide DOSH Compliance Manager and Occupational Nurse Consultant prior to the closing conference.An employer's general obligation to provide a "safe and healthful workplace" under the Washington Industrial Safety and Health Act (WISHA) includes exposure to harmful diseases. Due to the relatively recent recognition of the potential occupational hazards related to the 2009 H1N1 influenza virus , the potential lack of employer knowledge on this issue, and the recent adoption of DOSH Direction ion this issue, all 2009 H1N1 influenza related inspections shall be reviewed by the statewide DOSH Compliance Manager and Occupational Nurse Consultant prior to the closing conference.

    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 The use of respiratory protection at least as effective as fit-tested N95 disposable respirators is required for health care workers who have close contact (within 6 feet) with suspect or diagnosed H1N1 influenza patients. In the case of respirator shortages, prioritized use protocols may be implemented. All efforts should be made to provide at least fit tested N95 level protection to employees present during the performance of aerosol generating procedures. WAC 296-842, Respirators applies to all respirator use. Note: WAC 296-842 -13005 requires use of CDC guidelines for select biologic agents. The use of respiratory protection at least as effective as fit-tested N95 disposable respirators is required for health care workers who have close contact (within 6 feet) with suspect or diagnosed H1N1 influenza patients. In the case of respirator shortages, prioritized use protocols may be implemented. All efforts should be made to provide at least fit tested N95 level protection to employees present during the performance of aerosol generating procedures. WAC 296-842, Respirators applies to all respirator use. Note: WAC 296-842 -13005 requires use of CDC guidelines for select biologic agents.

    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 patients room. When workplace controls are not feasible or are not enough to protect workers, employers must provide appropriate personal protective equipment and ensure its use. For job tasks where close contact with 2009 H1N1 flu patients cannot otherwise be eliminated, the use of a fit-tested N95 disposable respirator or better is required for healthcare personnel whose job duties require them to be in close contact (within 6 feet or entering into a small enclosed airspace (e.g., average patient room) shared with the patient) with confirmed or suspected 2009 H1N1 flu patients and for personnel performing high-risk aerosol-generating procedures on such patients. Employers who require workers to wear respiratory protection (including N95 disposable respirators or better) must have a complete respiratory protection program in place in accordance with WAC 296-842 The demand for disposable respirators may exceed available supplies during the 2009-2010 flu season. It is critical that employers make a good faith effort to obtain respirators and use all available means to maximize the availability of respiratory protection. Additional information about respirator use and assigning priorities is included below and on the CDC 2009 H1N1 website. When workplace controls are not feasible or are not enough to protect workers, employers must provide appropriate personal protective equipment and ensure its use. For job tasks where close contact with 2009 H1N1 flu patients cannot otherwise be eliminated, the use of a fit-tested N95 disposable respirator or better is required for healthcare personnel whose job duties require them to be in close contact (within 6 feet or entering into a small enclosed airspace (e.g., average patient room) shared with the patient) with confirmed or suspected 2009 H1N1 flu patients and for personnel performing high-risk aerosol-generating procedures on such patients. Employers who require workers to wear respiratory protection (including N95 disposable respirators or better) must have a complete respiratory protection program in place in accordance with WAC 296-842 The demand for disposable respirators may exceed available supplies during the 2009-2010 flu season. It is critical that employers make a good faith effort to obtain respirators and use all available means to maximize the availability of respiratory protection. Additional information about respirator use and assigning priorities is included below and on the CDC 2009 H1N1 website.

    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 30

    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 underconsidered to be contaminated and not available for extended use or re-use. Guidance on reuse of respirators can be obtained from the CDCs website at: www.cdc.gov/h1n1flu/guidelines_infection_control_qa.htm 31 Shortages of respirators may occur, employers are encouraged to maintain a reserve of N95 or higher respirators for healthcare workers caring for patients with other infections for which respirator use is the standard ( e.g., tuberculosis), and for healthcare workers at high risk of exposure, such as those performing an aerosol generating procedure on a patient with suspect or diagnosed H1N1 influenza. Aerosol-generating procedures are defined as bronchoscopy; sputum induction; endotracheal intubation and extubation; open airway suctioning; cardiopulmonary resuscitation; and autopsies. In the event of a respirator shortage, a system for prioritized respirator use must be established. Additional guidance on the reuse of respirators is provided by the Association of Professionals in Infection Control and Epidemiology http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/APIC_Position_Ext_the_Use_and_or_Reus_Resp_Prot_in_Hlthcare_Settings1209l.pdf Shortages of respirators may occur, employers are encouraged to maintain a reserve of N95 or higher respirators for healthcare workers caring for patients with other infections for which respirator use is the standard ( e.g., tuberculosis), and for healthcare workers at high risk of exposure, such as those performing an aerosol generating procedure on a patient with suspect or diagnosed H1N1 influenza. Aerosol-generating procedures are defined as bronchoscopy; sputum induction; endotracheal intubation and extubation; open airway suctioning; cardiopulmonary resuscitation; and autopsies. In the event of a respirator shortage, a system for prioritized respirator use must be established. Additional guidance on the reuse of respirators is provided by the Association of Professionals in Infection Control and Epidemiology http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/APIC_Position_Ext_the_Use_and_or_Reus_Resp_Prot_in_Hlthcare_Settings1209l.pdf

    32. Respiratory Protection (continued) Citations shall be issued for the failure to provide a respirator at least as effective as an N95 filtering facepiece unless 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. 32 CSHOs must cite WAC 296-842-13005 for not providing a respirator at least as effective as an N95 respirator to employees providing care in close-contact of suspected or diagnosed 2009 H1N1 influenza patients. A shortage may exist if, under expected conditions of use, current supplies of disposable respirators are not expected to last past the next confirmed delivery date, and alternatives such as elastomeric respirators or PAPRS are not sufficient to cover all expected needs. Employers must establish and document all of the following: 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 has requested respirators through the Department of Health; 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. Note: Employers should be able to demonstrate exploration of a variety of sources of respiratory protection. For example, both healthcare and industrial safety vendor and manufacturer websites. Vendor contracts and respirator fit testing logistics will not be accepted as sufficient grounds for declaring a respirator shortage. NIOSH has developed a respirator resource page at: http://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource.html In the event extended use or re-use of N95 respirators becomes necessary, the same healthcare worker is permitted to extend use or re-use the respirator, 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 which a disposable respirator will be considered to be contaminated and not available for extended use or re-use. Guidance on reuse of respirators can be obtained at: www.cdc.gov/h1n1flu/guidelines_infection_control_qa.htm and http://www.apic.org/Content/NavigationMenu/EmergencyPreparedness/PositionPapers/Reuse_of_Respirators.pdf CSHOs must cite WAC 296-842-13005 for not providing a respirator at least as effective as an N95 respirator to employees providing care in close-contact of suspected or diagnosed 2009 H1N1 influenza patients. A shortage may exist if, under expected conditions of use, current supplies of disposable respirators are not expected to last past the next confirmed delivery date, and alternatives such as elastomeric respirators or PAPRS are not sufficient to cover all expected needs. Employers must establish and document all of the following: 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 has requested respirators through the Department of Health; 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. Note: Employers should be able to demonstrate exploration of a variety of sources of respiratory protection. For example, both healthcare and industrial safety vendor and manufacturer websites. Vendor contracts and respirator fit testing logistics will not be accepted as sufficient grounds for declaring a respirator shortage. NIOSH has developed a respirator resource page at: http://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource.html In the event extended use or re-use of N95 respirators becomes necessary, the same healthcare worker is permitted to extend use or re-use the respirator, 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 which a disposable respirator will be considered to be contaminated and not available for extended use or re-use. Guidance on reuse of respirators can be obtained at: www.cdc.gov/h1n1flu/guidelines_infection_control_qa.htm and http://www.apic.org/Content/NavigationMenu/EmergencyPreparedness/PositionPapers/Reuse_of_Respirators.pdf

    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 employees 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. 33

    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. 34

    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. 35

    36. Citation Guidelines (continued) Other DOSH Standards Commonly Associated with Healthcare Employers Bloodborne Pathogens. Compliance is required as per 296-823. 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. 36

    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 38

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

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