Pandemic Influenza Guidance is Being Revised

Editor's note: The updated guidance was posted to the Federal Register on June 22, 2010. To access this document, CLICK HERE.

Several federal entities are in the process of revising current guidance to reflect current thought on strategies for the prevention of pandemic influenza and other respiratory infections.

The Centers for Disease Prevention and Control (CDC) is updating its document, “Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel,” with new information that has become available.

The CDC acknowledges that when the interim infection control guidance for 2009 H1N1 was posted, “substantial uncertainties existed regarding the severity of disease and health impact of the novel H1N1 influenza strain, a high proportion of the population was susceptible to the new virus, and the vaccine was not available.” Circumstances have changed significantly since then, the CDC says, noting, “First, a safe and effective vaccine has become widely available. Second, we now have information about the number of cases of disease, hospitalizations, and deaths caused by 2009 H1N1, which can be compared to historical seasonal influenza data. The current circumstances justify an update of the recommendations.”

In updating this particular guidance document, the CDC says it will consolidate recommendations into a comprehensive, easily accessible document. Currently, experts at the CDC and other federal agencies are reviewing and editing the guidance, after which time input from the public will be sought. After the guidance is reviewed by experts within the federal government, it will be published in the Federal Register. In that way, all who are interested may review and submit comments on the content, and CDC will consider those comments before finalizing and publishing the guidance. The CDC will announce when the document is published in the Federal Register.

In addition, the Institute of Medicine (IOM) is examining current research directions and certification and testing issues regarding the use of personal protective equipment (PPE) during an influenza pandemic. The study is focused on research and other relevant efforts conducted since the release of the IOM report, “Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers” in September 2007. In that 2007 report, the IOM examined PPE -- the respirators, gowns, gloves, face shields, eye protection, and other equipment used by healthcare workers and others in their day-to-day patient care responsibilities -- as a vital component of pandemic influenza planning.

The report is a result of the challenge set before the IOM by the National Personal Protective Technology Laboratory (NPPTL) at the National Institute for Occupational Safety and Health (NIOSH), which in 2006 asked the IOM to conduct a study on the PPE needed by healthcare workers in the event of an influenza pandemic. The IOM committee determined that there is an urgent need to address the lack of preparedness regarding effective PPE for use in an influenza pandemic. Three critical areas were identified that require expeditious research and policy action: understand influenza transmission; commit to worker safety and appropriate use of PPE; and innovate and strengthen PPE design, testing and certification.

Interim Flu Recommendations: A Review

Until the updated pandemic influenza guidance is released, the Centers for Disease Prevention and Control (CDC) suggests that healthcare facilities review and, if not already in place, develop written pandemic influenza plans anticipating widespread transmission of 2009 H1N1 influenza in communities. The 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. 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. The CDC says that "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."

The CDC recommends that healthcare institutions use a hierarchy of controls to prevent exposure of healthcare personnel and patients and prevent influenza transmission within healthcare settings. The hierarchy of controls to protect workers from occupational injury or illness places preventive interventions in groups that are ranked according to their likely effectiveness in reducing or removing the source of exposure. To apply the hierarchy of controls to prevention of influenza transmission, facilities should take the following steps, in order of preference:

1. Elimination of potential exposures:  Eliminating the potential source of exposure ranks highest in the hierarchy of controls. Examples of interventions in this category include: 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. 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. Examples of engineering controls include installing partitions in triage areas and other public spaces, to reduce exposures by shielding personnel and other patients; and using closed suctioning systems for airways suction in intubated patients.

3. 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. Examples of administrative controls include promoting and providing vaccination; enforcing exclusion of ill healthcare personnel, implementing respiratory hygiene/cough etiquette strategies; and 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. Personal protective equipment (PPE): PPE ranks lowest in the hierarchy of controls. It is a last line of defense for individuals against ha-zards that cannot otherwise be eliminated or controlled. While providing personnel with appropriate PPE and education in its use is important, effectiveness of PPE is dependent on a number of factors. PPE is effective only if used throughout potential exposure periods. PPE will not be effective if adherence is incomplete or when exposures to infectious patients or ill co-workers are unrecognized. In addition, PPE must be used and maintained properly, and must function properly, to be effective.

Careful attention to elimination of potential exposures, engineering controls, and administrative controls will reduce the need to rely on PPE, including respirators.

It should be recognized that individual interventions may have a level of importance different from that suggested by their classification within the hierarchy of controls. For example, vaccination is an administrative control that depends upon the actions of both management and employees. However, vaccination is one of the most important interventions for preventing transmission of influenza to healthcare personnel. Its ability to prevent influenza transmission in both work and community settings is especially important, because influenza is a community-based infection that is transmitted in household and community settings. Other interventions that work in healthcare settings alone will not prevent such transmission.

For further recommendations, visit: http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm