Yesterday the Centers for Disease Control and Prevention (CDC) issued updated guidance on infection control measures aimed at preventing the transmission of H1N1 influenza in healthcare facilities. See Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. While continuing its emphasis on employing a comprehensive approach to preventing the transmission of H1N1 through the development of flexible and adaptable written plans, the CDC has revised its earlier guidance by, among other things, including criteria for the identification of suspected influenza patients, recommending a prescribed amount of time away from work for healthcare personnel and changing isolation precautions based on tasks and anticipated exposures. In an attempt to help healthcare employers understand this updated guidance, the CDC also has issued an accompanying Question and Answer series. Summarized below, these instructive publications should be closely reviewed by all employers, particularly those in the healthcare field.
Utilizing a "Hierarchy of Controls"
In applying what the CDC calls a "hierarchy of controls" to prevent exposure and transmission of H1N1 influenza among healthcare personnel and patients, healthcare facilities should take the following steps:
(1) Eliminate potential exposures by taking steps to minimize outpatient visits for patients with mild influenza-like illness who do not have risk factors for complications, postponing elective visits by patients with suspected or confirmed influenza until they are no longer infectious, and denying entry to visitors who are sick.
(2) Employ engineering controls by installing partitions in triage areas and other public spaces and using closed suctioning systems for airways suction in intubated patients.
(3) Implement administrative controls by promoting and providing vaccinations, enforcing exclusion of ill healthcare personnel, implementing respiratory hygiene/cough etiquette strategies, setting up triage stations and separate areas for patients who visit emergency departments with influenza-like illness, managing patient flow, and assigning dedicated staff to minimize the number of healthcare personnel exposed to those with suspected or confirmed influenza.
(4) Provide healthcare personnel with personal protective equipment (PPE), including respirators when necessary. Notably, the CDC issued a supplemental Question and Answer series specially designed to address concerns related to the use of respiratory protection.
Specific Recommendations from the CDC
· The CDC's number one recommendation for preventing the transmission of the H1N1 influenza is the promotion and administration of vaccinations by healthcare facilities. To improve adherence to this recommendation, the CDC suggests that both the H1N1 and seasonal flu vaccinations should be offered to healthcare personnel free of charge and during working hours.
· Strictly enforce respiratory hygiene and cough etiquette. This form of source control should be implemented by everyone in healthcare settings – patients, visitors and staff alike.
· Establish facility access control measures and triage procedures, including the creation of non-punitive policies that encourage or require ill healthcare personnel workers to stay home.
· Manage visitor access and movement within the facility.
· Establish policies and procedures for patient placement and transport. Any patient with respiratory illness consistent with influenza should promptly be asked to wear a facemask for source control, if tolerated, or cover their nose and mouth with tissues when coughing or sneezing, and placed directly in an individual room with the door kept closed, where medically appropriate.
· Follow current facility procedures for transport and movement of patients under isolation precautions, including communicating information about patients with suspected, probable or confirmed influenza to appropriate personnel before transferring them to other departments in the facility (e.g., radiology, laboratory) and to other facilities.
· Limit the number of healthcare personnel entering the isolation room.
· Apply isolation precautions, such as the use of nonsterile gloves, gowns, eye protection, facemasks, and respiratory protection.
· Require thorough hand hygiene.
· Minimize aerosol-generating procedures, such as bronchoscopies, sputum inductions, endotrachael intubation and extubation, cardiopulmonary resuscitation and autopsies.
Duration of Isolation Precautions for Patients
The CDC recommends that isolation precautions for patients who have influenza symptoms should be continued for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility. Shedding of influenza viruses generally diminishes over the course of 7 days, with transmission apparently correlating with fever. If isolation resources (e.g. private rooms) become limited, these resources should be prioritized for patients who are earlier in the course of illness. Finally, patients should be discharged from medical care when clinically appropriate, not based on the period of isolation.
Monitor and Manage Ill Healthcare Personnel
The CDC recommends that healthcare employers establish procedures for tracking staff absences, reviewing job tasks and identifying personnel at higher risk for complications, assuring that employees have access via telephone to medical consultation and, if necessary, early treatment, and promptly identifying individuals with possible influenza. Personnel should be provided with information about risk factors for complications of influenza, so those at higher risk know to promptly seek medical attention and be evaluated for early treatment if they develop symptoms of influenza. All personnel should be provided with specific instructions to follow in the event of respiratory illness with rapid progression, particularly when experiencing shortness of breath. Anyone with the following emergency warning signs needs urgent medical attention and should seek medical care promptly:
· Difficulty breathing or shortness of breath
· Pain or pressure in the chest or abdomen
· Sudden dizziness
· Confusion
· Severe or persistent vomiting
· Flu-like symptoms improve but then return with fever and worse cough.
Healthcare personnel who develop a fever and respiratory symptoms should be:
· Instructed not to report to work, or if at work, to promptly notify their supervisor and infection control personnel/occupational health.
· Excluded from work for at least 24 hours after they no longer have a fever, without the use of fever-reducing medicines.
· If returning to work in areas where severely immunocompromised patients receive care, considered for temporary reassignment or exclusion from work for 7 days from symptom onset or until the resolution of symptoms, whichever is longer.
· Reminded of the importance of practicing frequent hand hygiene (especially before and after each patient contact) and respiratory hygiene and cough etiquette after returning to work following an acute respiratory illness.
Healthcare personnel who develop acute respiratory symptoms without fever should be:
· Allowed to continue or return to work unless assigned in areas where severely immunocompromised patients are provided care. In that case, they should be considered for temporary reassignment or exclusion from work for 7 days from symptom onset or until the resolution of symptoms, whichever is longer.
· Reminded of the importance of practicing frequent hand hygiene (especially before and after each patient contact) and respiratory hygiene and cough etiquette after returning to work following an acute respiratory illness.
Facilities and organizations providing healthcare services should:
· Ensure that sick leave policies for healthcare personnel (e.g., staff and contract personnel) are flexible and consistent with public health guidance and that employees are aware of the policies.
· Ensure that sick employees are able to stay home without fear of losing their jobs.
· Consider offering alternative work environments as an accommodation for employees at higher risk for complications of 2009 H1N1 influenza during periods of increased influenza activity or if influenza severity increases.
· Not require a doctor’s note for workers with influenza to validate their illness or return to work.
Training and Education of Healthcare Personnel
The CDC advises that training on influenza prevention and risks for complications of influenza should include information on risk assessment; isolation precautions; vaccination protocols; use of engineering and administrative controls and personal protective equipment; protection during high-risk aerosol-generating procedures; signs, symptoms, and complications of influenza; and to promptly seek medical attention for any concerns about symptoms of influenza.
Healthcare Personnel at Higher Risk for Complications of Influenza
According to the CDC, personnel at higher risk for complications from influenza infection include pregnant women, persons 65 years old and older, and persons with chronic diseases such as asthma, heart disease, diabetes, diseases that suppress the immune system, and certain other chronic medical conditions. Vaccination and early treatment with antiviral medications are particularly important for these individuals.
Environmental Infection Control
The CDC concludes its revised guidance by reminding employers that routine cleaning and disinfection strategies used during typical influenza seasons can be applied to the environmental management of H1N1 influenza. Management of laundry, utensils and medical waste also should be performed in accordance with procedures followed for seasonal influenza.
If you have any questions or concerns after reviewing the updated CDC guidance, please do not hesitate to contact your regular Hall Render attorneys, Travis Meek (tmeek@hallrender.com; 317-977-1489) or Jennifer Richter (jrichter@hallrender.com; 317-977-1477).
MMMMMMMMMMMMMMMMMM | 
