Pandemic Flu: Protecting Employees in Non-Health Care Environments

1. Pandemic Flu:Protecting Employees in Non-Health Care Environments 5-27-2009 Deborah Gold, MPH, CIH, dgold@hq.dir.ca.gov Senior Safety Engineer Cal/OSHA

3. Swine Flu2009 Influenza A H1N1 SOI • Apparently started in Mexico, originally 150 deaths reported, now WHO reports 83 deaths out of 4541 confirmed cases • U.S., 6764 cases, 10 deaths (confirmed) • 921 cases Canada • Also numerous cases in Spain, Japan, UK

7. U.S. Laboratory Confirmed Influenza Cases (Week Ending May 16) Source: CDC, http://www.cdc.gov/flu/weekly/

8. http://www.who.int/csr/don/2009_05_27a/en/index.html

10. Non-infection Impacts on Health and Safety • Employee absences and changes in commerce may result in reassignment of employees • may require additional training for employees and supervisors not accustomed to tasks • School closures • Disruption of supplies • Supplies used in general industry, such as respirators, gloves, towels, etc. may be in short supply

11. Continuing H1N1 Concerns • Virus is circulating in various countries • At least one case of probable human to animal transmission (Canadian) • Potential for mixing with other influenza viruses • Will it impact fall flu season (e.g. 1918)?

12. OSHA Risk Pyramid HCW – Aerosol Generating Procedures HCW High Frequency Contact with General Population Minimal contact with general public and other co-workers http://www.osha.gov/Publications/employers-protect-workers-flu-factsheet.html

13. Public Contact • Schools • Grocery checkers, bank tellers, etc. • Public offices such as social services, DMV • Some public transit and terminals

14. Workers Providing Health Care in Industry or Retail Environments • On-site clinics/ employee health • Retail health care • Pharmacies

15. Controls

16. OSHA’s suggested Control Measures for public contact • Sneeze guards, drive through windows and other barriers • Ventilation • Social distancing • Respiratory hygiene and hand hygiene • Cleaning and disinfection of surfaces and hands

17. CDPH Guidance for State Facilities Employees • Stay home if sick • Seek medical care if severe symptoms or if at increased risk • If you need to go out when sick, wear a mask to protect others • Wash hands frequently (or alcohol hand san) • Cover coughs and sneezes • Avoid touching eyes, nose mouth • Keep distance from people who are coughing • Avoid sharing personal items http://www.cdph.ca.gov/HealthInfo/discond/Documents/CDPH-H1N1GuidanceforStateFacilities.pdf

18. CDPH Guidance for State Facilities supervisors and managers • Review and update plans • Tell ees to stay home or go home if sick (7 days from onset) • E-mail, telework, teleconferences, web to minimize face-to-face • Maintain supply of tissues and hand hygiene products • Alcohol based hand san for staff, visitors, and residents • Avoid touching eyes, nose mouth • Clean common areas daily, increase cleaning of freq touched surfaces • Post signs – cover cough • Increase outdoor air ventilation, by opening windows or increase outdoor air supply rate if feasible (Myatt, TA et al. Detection of Airborne Rhinovirus and Its Relation to Outdoor Air Supply in Office Environments, AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 169 2004)

19. Personal Protection We don’t Know: • The specific route of transmission • Contact with eyes and mucous membranes • Inhalation and site of infection • Whether the use of surgical masks or tissues by the source patient will provide added protection

20. Respirator Use • Section 5144 regulates respirator use in the workplace • Requires medical evaluation, training and fit-testing • Employers who plan for employee respirator use in a pandemic should prepare in advance

21. Surgical Masks vs. Respirators • Surgical masks are cheap and available • Surgical masks don’t require fit-testing • Some have recommended the use of multiple surgical masks when N95’s weren’t available • Filtration of surgical masks is highly variable • Evidence does not support effectiveness of surgical masks against respiratory viruses

22. Respirators and Surgical Masks

23. Do N95’s need to be fit-tested? 1996 NIOSH laboratory study of 25 subjects with 21 models of N95s found • Without fit-testing, the average protection factor for all subjects using a respirator was 3. • By selecting out bad fits, using a fit-test, the average protection factor was 25 • Only four models passed a fit-test (factor of 100) for the majority of participants. Three did not pass the fit-test for any participant. Laboratory Performance Evaluation of N95 Filtering Facepiece Respirators, 1996. MMWR Morb Mortal Wkly Rep. 1998 Dec 11;47(48):1045-9.

24. Respirators vs. Surgical Masks Robert B. Lawrence, Matthew G. Duling, Catherine A. Calvert and Christopher C. Coffey , 'Comparison of Performance of Three Different Types of Respiratory Protection Devices', JOEH 3:9, 465 - 474

25. Respirator Supply Issues • California has “stockpiled” about 40 million N95 filtering facepiece respirators for use in health care • Hospitals • Some were able to shift stock • Some ran out in first week • Medical suppliers reported shortages • Safety suppliers generally had stock, and directed it to health care and local gov.

26. Respirator Use Questions • FDA considers FF respirator in medical setting to be a single use medical device • Can respirators be re-donned? • If so, under what conditions? • Is the respirator a hazard to patient? • IOM report Reusability of Facemasks During an Influenza Pandemic: Facing the Flu available from www.nap.edu • We have requested information from OSHA

27. Respirator fit testing • Some respirators are similar design, but different materials, e.g. • Current regulations require a fit test if N95 is substituted for surgical N95 9210 – N95 1870 Surgical N95

28. IIPP • Every CA employer required to have an Injury and Illness Prevention Program (Section 3203) • IIPP’s should address infectious diseases hazards of some occupations, e.g. health care, wildlife biologists. • If a flu epidemic creates workplace hazards, OSHA and Cal/OSHA will issue additional guidance. • The absence of a specific requirement to plan for pandemic flu should not prevent employers from assessing risks and developing plans

29. IIPP Pandemic flu may impact existing IIPP’s • Incorporate infection control measures • Need to assess hazards due to changes in processes, supplies, products or use of space (e.g. alternate care sites) • Would require additional training for employees

30. Recording • Log 300 exempts recording of “common cold and flu” • Are pandemic flu strains, or zoonotic flu strains included in this exemption? • OSHA will make this determination – must be consistent in all states

31. Health Care Emergency • If the governor declares a state of emergency, he may suspend some regulations • H1N1 JEOC established with CDPH and Cal EMA • No regulations suspended • Issues of stockpile access • The need to protect employees at work will remain – whether it is through enforcement or other mechanisms • Cal/OSHA will provide guidance as the situation unfolds

32. Resources • OSHA -- Guidance on Preparing Workplaces for an Influenza Pandemic http://www.osha.gov/Publications/influenza_pandemic.html#affect_workplaces • Cal/OSHA on the web: www.dir.ca.gov • California Department of Public Health: http://www.cdph.ca.gov/HealthInfo/discond/Pages/SwineInfluenza.aspx