Pandemic Influenza Planning for the Long-Term Healthcare Workplace

1. Pandemic Influenza Planning for the Long-Term Healthcare Workplace Georgia Tech OSHA Consultation Program GHCA Annual Convention June 2008 Information Provided under OSHA Susan Harwood Grant #SH-16620-07-60-F-13

2. Agenda Day 1 • Definitions • Transmission • Projections • Break • Current Status • Surveillance Principles; ICS & NIMS • Introduction to Exposure Reduction • Part A Workshop and Homework

3. Agenda Day 2 • Exposure Reduction (continued) • Personal Protective Equipment • Respiratory Protection • Break • Development/Implementation of Business Continuity and Preparedness Plan • Part B Workshop and Game

6. Seasonal Influenza Symptoms • Fever (usually high) and chills • Body aches • Sore throat • Non-productive cough (dry) • Runny or stuffy nose • Headache • Extremely tired (fatigue) • Diarrhea Symptomatic: 1-4 days (exposure to onset); average = 2 days Infectious: 1 day before to 5 days after symptomatic illness Recovery: 3-7 days

8. Avian Influenza • Birds (wild and domestic poultry) are natural reservoirs of all influenza A viruses • Rarely infect humans • Flu types can be either be of low or high pathogenicity (ability to cause disease) • Low pathogenic strains: wild domestic transmission; can mutate • Highly pathogenic strain: high bird death rate (example H5N1 virus) with rapid spread among domesticated fowl. Bird to human transmission possible.

11. Shifting from Avian Flu to Pandemic Flu • Expecting H5N1 (or a similar virus) to give rise to next Human flu pandemic • When the avian flu virus changes its genetic structure so that it is capable of infecting humans AND • It can be easily spread from human to human: Pandemic Influenza occurs

12. Pandemic Influenza • A disease outbreak that spreads rapidly and affects many people world wide. • Characteristics • New virus that spreads easily as most people are susceptible (no natural resistance or immunity) • Effective human to human transmission is necessary • Measured by how fast the virus spreads • Wide geographic spread • Not predictable • Outbreaks lasting 8-12 weeks with 1-3 week wave cycles

13. Pandemic Influenza Anticipated Illness • A severe form of seasonal flu symptoms • H5N1 cases in Asia reported seasonal flu symptoms with LOWER respiratory infection (rather than traditional UPPER respiratory infections) • Shortness of breath, viral pneumonia, abdominal pain, diarrhea, and vomiting in higher prevalence than seasonal flu

14. Influenza Photo credit: A. Davidhazy 2002

15. Pandemic Influenza Transmission • Not yet known which of three routes of transmission will be MOST important • Possibilities • Droplet (large droplets produced during coughs and sneezes) (eg seasonal flu) • Airborne (very small infectious particles able to travel long range distances) (eg TB) • Contact (hand to mouth and/or nose contact; contact with contaminated surfaces)

16. Projections: What Lies Ahead • What are the projected numbers? • What is the projected magnitude of impact? • What to expect?

17. Characteristic Moderate (1958/68-like) Severe (1918-like) Illness 90 million (30%) 90 million (30%) Outpatient medical care 45 million (50%) 45 million (50%) Hospitalization 865,000 9,900,000 (11%) ICU care 128,750 1,485,000 Mechanical ventilation 64,875 745,500 Deaths 209,000 1,903,000 Impact of Pandemic FluUnited States (ESTIMATES for TODAY’S WORLD)

18. What’s this mean for Georgia? • How many licensed hospital beds in Georgia? • 23,000 • How many of those beds are staffed? • 16,000 • How many people are anticipated to be sick in Georgia? • 3 million • How many of those sick will need hospitalization? • 60,000 to 330,000 • How many of those hospitalized will need ventilators? • 4500 to 24,750 • How many ventilators do we have in Georgia? • 1500 Who is operating these ventilators and performing the work when 40-60% of the workforce is absent?

19. Pandemic Waves • Pandemics occur in multiple waves of disease outbreaks • The first wave in a local area is likely to last six to eight weeks • The time between pandemic waves varies and can not be easily predicted. • Anticipate 1-3 waves

20. What to Expect • Crisis for extended period of time in multiple locations • Daily routines will be affected from personal, community, and professional changes • Isolation/quarantine guidelines or requirements? • Cancellation of public events and schools? • Non-essential work activities limited? • Commerce Patterns changed? • Elements of personal action will be required • Absenteeism from pandemic flu expected to be 40-60% • Lost availability for those who are ill (or caring for ill family) is projected at 2-4 weeks

21. Impact on the Health Care System • Extreme staffing shortages • Shortages of beds, facility space, key supplies (ventilators, drugs) • Hospital morgues, Medical Examiner and mortuary services will be overwhelmed • Extreme demands on social and counseling services • Long-term: demand will outpace supply

22. Specific Risks to Long-Term Health Care Community • Potentially already immune-compromised • Living in close proximity • Visitors from outside • Surfaces • Activities • Employees

23. Is a Vaccine Available? • A vaccine to protect people from pandemic flu is not available now. • A vaccine may not be available at the start of a flu pandemic (~ 6-8 months after start) • The best protection is to practice healthy hygiene to stay well now and during a flu pandemic.

24. Current Status • Where are we now? • What preparation has been done so far? • Federal level • State level • What available tools do we need to understand to prepare better at the local level?

25. Is there a Pandemic now? • As of 3 January 2008: • Reported to World Health Organization (WHO); cumulative total confirmed human cases of Avian Influenza A H5N1 virus: • 348 cases • 216 deaths • No sustained human to human transmission identified = currently NO pandemic

26. Risk Classification Structure Who’s Who: World Health Organization (Phases 1-6) US Government (Stages 1-5) Centers for Disease Controland Prevention — CDC (Categories) OSHA Risk Pyramid

27. U.S. Government and WHO: A Comparison

28. CDC Severity Index

29. What is surveillance? • Ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control.

30. Public Reports Health CareProviders Summaries,Interpretations,Recommendations HealthAgencies Analysis Information Loop of Public Health Surveillance Source: Denise Koo, MD, MPHEpidemiology Program Office, Centers for Disease Control and Prevention

32. Pandemic Influenza SurveillanceResponsibility at all levels: • Globally- World Health Organization • WHO Global Influenza Surveillance Network • National Influenza Centres (NICs) • WHO Collaborating Centres (WHO CCs) • Nationally- Health and Human Services • National Influenza Surveillance System • Influenza Surveillance coordinators • State and Local governments • Support national and global surveillance systems

33. Surveillance Recommendations for Interpandemic and Pandemic Alert Periods • State and local responsibilities: • Continue to employ state influenza surveillance coordinators to oversee improvements in influenza surveillance • Conduct influenza surveillance year round, where possible. • Implement enhanced surveillance for detection of the first U.S. cases of novel virus infection. • State and large local public health laboratory responsibilities: • Isolate and subtype influenza viruses year round. • Improve capacity for rapid identification of unusual influenza strains

34. Recommendations for the Pandemic Period If an influenza pandemic begins in the United States or another country: • State and local responsibilities: • Implement enhanced surveillance for detection of the first cases. • Enhance all influenza surveillance components (virologic, outpatient, hospitalization, and mortality). • Communicate to all partners the heightened need for timely and complete surveillance data. • HHS responsibilities: • Provide technical support, as requested, to ministries of health and WHO to track the pandemic virus and gather epidemiologic data on risk factors for infection or severe illness. • Issue updated case definitions and guidance for laboratory testing and enhanced surveillance. • Assist state and local health departments, as requested. • Analyze influenza surveillance data on a regular and timely basis. For more information: http://www.hhs.gov/pandemicflu/plan/pdf/S01.pdf

35. Keep records of and monitor: Who cares for sick patients Which employees Show signs of disease Become ill Recover Absenteeism Encourage self-reporting of symptoms by employees Educate employees about transmission Perform Serologic testing on employees, where possible Prioritize employees with serologic evidence of pandemic flu for care of patients Remove employees with increased risk of complications due to pandemic flu OSHA Surveillance Recommendations for Healthcare Providers

36. Incident Command &Health Care Workers • When pandemic flu arrives & starts to manifest itself, many original discoverers of infected & seriously ill people will be public safety first responders • Public safety, especially fire & EMT services, work within Incident Command System (ICS) that utilizes standardized terminology & concepts in order to efficiently & safely address emergencies and other kinds of incidents • http://training.fema.gov/EMIWeb/IS/is200HC.asp • http://training.fema.gov/EMIWeb/IS/is100HC.asp

37. Incident Command &Health Care Workers • During a pandemic, private HCWs will not be able to work in a vacuum by themselves • Will have to coordinate & interface with public safety • Will have to understand the language & be able to work within the ICS • Private entities have compliance responsibilities under National Incident Management System (NIMS)

38. Through the use of NIMS/ICS, all types of response activities, to include in-house management of infected people, will be more efficient and ultimately safer for all involved

39. National Incident Management System (NIMS) and Incident Command System (ICS) • Incident Command System (ICS) • Public safety, especially fire & EMT services • utilizes standardized terminology & concepts in order to efficiently & safely address emergencies and other kinds of incidents • National Incident Management System (NIMS) • Private entities have compliance responsibilities under • NIMS is mandated for adoption across all spectra of response organizations • public & private; • government; • non-governmental organizations; • and private businesses

40. Exposure Reduction and General Infection Control Practices

41. HHS & CDC Plan • GOAL: Slow the spread to reduce incidence of illness and death • Hospitals/Healthcare System Overloaded • Use social distancing, targeted antiviral treatment, isolation and quarantine to buy time to increase: • Antiviral supply • Vaccine availability Impact Unprepared Prepared Weeks

42. Source Substitution Source Reduction Procedures Ventilation Personal Protection Avoid the need Reduce the need Reduce exposure Dilute and Divert Personal barriers Hierarchy of Controls Preference

43. Tiered Readiness Approach • Personal Readiness • Family and Community Readiness • Workplace Readiness INFORMATION = POWER • Example: Personal Readiness – planning now to care for yourself or loved ones who get the flu = better equipped to respond in Workplace Readiness • Example: encourage employees to obtain a seasonal flu vaccine (as normal flu will probably continue to circulate). Multiple Level Impact requires Multiple Level Planning

44. Variable Guidance Depending on Risk Classification Level • Lower Exposure Risk • Medium Exposure Risk • High Exposure Risk • OSHA Guidance on Preparing Workplaces for an Influenza Pandemic (OSHA 3327-02N 2007) Expect majority of American workforce will be in these 2 categories

45. Healthcare employees performing aerosol-generating procedures on known or suspected patients Healthcare delivery & support staff entering known or suspected patient rooms

46. Stratifying Risk: How Likely Will I Be Infected? In Healthcare settings: ++++ Aerosol generating procedures performed on influenza patients ++++ Resuscitation of a patient with influenza (i.e., emergency intubation, CPR, etc.) ++/+++ Direct patient care for a symptomatic (ill) patient suspected to have influenza ++ Direct routine patient care for all other patients ++ Home care for a family member ill with influenza ++ Non-patient-care activities in a healthcare setting

47. Workplace Readiness • Surface Cleaning, Facility Hygiene and other Environmental Measures • Cough Etiquette • Hand Hygiene • Social Distancing • Limiting Face-to-Face Meetings • Employee and/or visitor screening • Personal Barriers • Contingency Planning/Business Continuity

48. Influenza virus can survive on surfaces at room temperature and moderate humidity: Steel and plastic: 24-48 hours Cloth and tissues: 8-12 hours Surfaces can include items such as: Tabletops Doorknobs Tools Computer keyboards and Telephone handsets Cloth, tissues, paper or currency infected with the virus Faucets, toilet flushers Potential for Contact Transmission and Surface Cleaning

49. Potential for Contact Transmission Effectively inactivated by: • Detergents • Alcohol-based products (hand gels) • Bleach solutions • Household disinfectants (virucides)

50. Facility Hygiene Practices and Policies