The EI Group, Inc.

Respiratory protection in the face of a pandemic

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Courtesy of The EI Group, Inc.

If 2009’s recent media coverage regarding the spread of the H1N1 virus caused your organization to reconsider whether you need a respiratory protection plan for your employees, you were not alone. David Lahoda, Managing Editor of OSHA Watch and contributor to OSHA Healthcare Advisor, recently blogged on the wake-up call many of us have received as we rush to get our respiratory protection plans up to speed. Organizations are wondering, “If I can get enough N95 respirators to protect my employees, what do I need to do to have my employees wear them?” Lahoda notes that time and planning are needed. Both of which seem to be in short supply right now.

In April 2009, the novel H1N1 virus was first identified. Subsequently, when human to human transmission was sufficiently sustained, the World Health Organization (WHO) classified its spread as a phase 6 pandemic. WHO classifies a pandemic on the basis on geographic spread rather the severity of the virus. Fortunately, the virus has proven to produce mainly mild to moderate symptoms similar to that of the seasonal influenza with some fatalities.

In response to growing fears in the United States, the Occupational Health and Safety Administration (OSHA) and several other public health agencies developed recommendations to assist employers in preparing their workplaces to minimize transmission of a pandemic virus. The Centers for Disease Control (CDC) responded quickly producing interim guidelines regarding respirator usage for the healthcare industry. 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).

OSHA has also taken the initiative in developing numerous guidelines to assist employers, many of which are published on OSHA’s 2009 pandemic Influenza Safety and Health Topics page, located at www.flu.gov. The Directorate of Training and Education (DTE) for OSHA has added additional outreach information in the form of a one-day pandemic influenza training course to educate employers. The OSHA Training Institute Centers will offer this free training.

More recently, in November 2009, OSHA issued a compliance directive to ensure inspection procedures to identify, minimize or eliminate high to very high-risk occupational exposures to the H1N1 Influenza A virus performed by field staff were conducted in a uniform manner. Acting Assistant Secretary of Labor for OSHA Jordan Barab was quoted stating, “OSHA has a responsibility to ensure that the more than nine million frontline health care workers in the United States are protected to the extent possible against exposure to the virus.” The directive defines “healthcare personnel,” as “all persons whose occupational activities involve contact with patients or contaminated material in a healthcare or clinical laboratory setting.” Additionally, healthcare personnel perform other tasks, many of which include patient contact even in the absence of direct patient care. Dietary and housekeeping services are among those services provided. Healthcare workplaces include not only hospitals and the office of private practitioners but also inpatient and outpatient facilities, senior adult care and home healthcare settings, and institutional settings such as colleges, universities, schools and correctional facilities.


Risk Categories
A worker's risk of occupational exposure during an influenza pandemic varies 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 confirmed 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.). OSHA notes that the compliance directive does not apply to medium or lower risk occupational exposures. Risk categories are defined as:

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
A job task or activity is in the Medium Exposure Risk category if it requires frequent, close contact (within 6 feet) with others (e.g., coworkers, the general public, school children, or other such individuals or groups).

Employees with high-frequency contact with the general population [such as schools (e.g., teachers), high population density work environments (e.g., tellers at banks), and some high-volume retail (e.g., cashiers at grocery stores)].

Lower Exposure Risk (Caution)
A job task or activity is in the Lower Exposure Risk category if it does not require frequent close contact (within 6 feet) with others (e.g., coworkers or the general public).

Employees who have minimal occupational contact with the general public and coworkers (for example, office workers).



Compliance Issues
The CDC finalized guidelines October 2009 and they present a new enforcement challenge for OSHA. Similar to safety enforcement during natural disasters, it is impossible to determine what regulators may be willing to overlook in the face of a pandemic, but the OSHA respiratory protection standard (29 CFR 1910.134) is clear regarding what employers must do to establish a compliant program.
Since H1N1 is transmitted via direct or indirect person-to-person spreading of infectious droplets when influenza patients cough, sneeze, talk, or even breathe, the use of respiratory protection for healthcare workers is a complex but timely topic. As good industrial hygiene would dictate, the CDC guidelines focus on the importance of source control (postponing visits by patients with confirmed or suspected influenza), engineering (partition installation in triage areas), and administrative (vaccination) measures to reduce the numbers of workers who come into contact with patients who have influenza-like illness. Personal protective equipment (PPE) ranks lowest in this hierarchy, as its effective use depends upon a number of factors including proper wearer use training and use during all potential exposure periods. Failure to comply with proper use requirements or an inability to recognize infected patients severely limits the effectiveness of the PPE. If respiratory protection is used, the CDC calls for respiratory protection at least as protective as a fit-tested disposable N95 respirator.
Therein lies the challenge for health care administrators. The CDC and OSHA’s hierarchy of controls is intended to extend the use of, or reduce the consumption of, what is likely the most often sought control mechanism other than vaccination – that of N95 filtering facepiece respirators. As distributors seek to fill all the orders for disposable respirators and fit testing kits, many organizations may find themselves left out in their attempt to comply. SavaSeniorCare affiliated nursing facilities with locations across the United States, decided to not contend with the possible shortage of N95 respirators and instead choose to be proactive and secure sufficient supplies in order to protect their employees and residents from exposure. Nan Impink, Senior Vice President and Chief Operations Counsel for SavaSeniorCare added, “We take seriously the health and safety of our residents and employees. Therefore, we decided to be proactive this year and assure that we were prepared for an H1N1 and/or seasonal influenza outbreak. Our customers expect that we will do what is needed to protect their loved ones. ”
CDC details prioritization of respirator protection during respirator shortages (although though no guidance is given defining a “respirator shortage”), shifting the focus to healthcare personnel attending aerosol generating procedures (considered a very high exposure risk situation) as well as to those managing patients with diseases others than influenza that require respiratory protection such as tuberculosis.
OSHA has indicated that where respirators are not commercially available an employer will be considered to be in compliance if the employer can show a “good faith” effort has been made to acquire respirators. CDC adds that facilities should “maintain a reserve sufficient to meet the estimated needs for performing aerosol generating procedures and for managing patients with diseases other than influenza that require respiratory protection until supplies are expected to be replenished.”

Alternatives not always immediately considered include the use of more protective filtering face pieces respirators such as elastomeric and reusable powered air purifying respirators (PAPRs). However, in these instances, adequate decontamination procedures must be followed closely. Other filtering facepieces classifications do equally (if not better) as well at reducing influenza exposure (N, P, R 99 and 100 designations). Surgical facemasks that have also been cleared by the U.S. Food and Drug Administration for their ability to resist blood and body fluids may also be provided to healthcare workers (while the employer/facility is in a prioritized respirator use mode) when no other protection is available.

Facemasks can also be placed on potentially infectious patients as an added measure of protection. Employers have a variety of options when it comes to respiratory protection against pandemic flu, however, they must be careful to consider in their respiratory protection plans under what specific circumstances extended use or re-use may become necessary and also a determination of when respirators will be considered contaminated and not available for re-use.
Respirator Medical Clearance

Where workers are required by employers to wear respirators (not surgical facemasks), the respirators must be NIOSH-certified, selected, and used in the context of a comprehensive respiratory protection program, (see OSHA standard 29 CFR 1910.134, or www.osha.gov/SLTC/respiratoryprotection/index.html). It is important to medically evaluate workers to ensure that they can perform work tasks while wearing a respirator. For many workers, a medical evaluation may be accomplished by having a physician or other licensed healthcare provider review a respiratory questionnaire completed by the worker (found in Appendix C of OSHA’s Respiratory Protection standard, 29 CFR 1910.134) to determine if the worker can be medically cleared to use a respirator. Increasingly, organizations are electing to have employees cleared by a Physician through online questionnaires.

Employers who have never before needed to consider a respiratory protection plan should note that it can take time to choose an appropriate respirator to provide to workers; arrange for a qualified trainer; and provide training, fit testing and medical evaluation for their workers. As SavaSeniorCare-affiliates’ facilities discovered, mobilizing almost 10,000 employees in 15 states working in over 180 facilities to complete medical questionnaires in a timely manner, having each one reviewed by an occupational health physician and subsequently providing training and fit testing is an incredible undertaking. OSHA anticipates inspecting facilities mainly in response to worker complaints and as part of fatality investigations where death or hospitalization occurred due to suspect occupational exposure to pandemic flu. OSHA does not intend to inspect formal complaints of H1N1 exposures where employees perform exposure risk tasks than are considered medium or lower risk. In the event an employer is inspected, they should be prepared to provide documentation of exposure or hazard assessments performed which lead to the decision to use respiratory protection and other protection equipment. The exposure assessment should detail employee exposure risk categories as previously defined. One element that may be easily overlooked is also a pandemic influenza plan as part of an overall emergency preparedness plan as recommended by CDC.

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