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AEROSOL
TRANSMISSIBLE
DISEASE
STANDARD
Riverside County
Department of Public Health
2010
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Learning Objectives
At the conclusion of this presentation
participants will be able to:
1. Identify at least 3 common Aerosol
Transmissible Diseases (ATD) that
present a risk in the workplace.
2. Identify the levels for potential exposure
of employees to ATD based on job
responsibilities.
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Learning Objectives (continued)
3. Discuss the difference between droplet
precautions and airborne infection
isolation.
4. Discuss appropriate action to take if
exposed to an ATD in the workplace.
5. Discuss the recommended Personal
Protective Equipment (PPE) for Novel
Influenza Viruses.
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Disease Trends
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Tuberculosis Rate
Riverside County, 1997-2009
Riverside County
California
HP 2010
Rate per 100,000 population
14
12
10
8
6
4
2
0
'98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09
Year
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MULTI DRUG RESISTANT (MDR)
Riverside County - TB Cases 2000-2009
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6
5
4
3
2
1
0
3
2
1
1
1
1
1
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
0
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
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Vaccine Preventable Diseases
Incident of Reportable Vaccine Preventable Diseases,
Riverside County 2003-2009
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Pertussis Cases by Year 1999-2010
Riverside County
Data through July 15, 2010
For current numbers go to http://www.rivcoph.org/pertussis/index.html
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H1N1 Riverside County
April 2009 –March 31, 2010
• Total Cases: 2,573
– Number Hospitalized: 389
– Number of Deaths: 40
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What is an Aerosol
Transmissible Disease
• A disease or pathogen that is
transmissible by aerosols (gaseous
suspension of fine solid or liquid particles)
• Airborne precautions: small droplets, or
droplet nuclei
• Droplet precautions:
larger droplets, 5 microns
or greater
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Symptoms of ATDs
(vary based on the disease)
• Varicella: fever, vesicular rash, crops of vesicles
• Measles: cough, fever, rash, conjunctivitis, koplik
spots
• Smallpox: rash with sudden onset of high fever,
malaise, severe back ache
• Pertussis: initial irritating cough gradually
progressing to repeated violent coughing, may
be followed by high pitched inspiratory whoop
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Symptoms of ATDs
(vary based on the disease cont.)
• Meningococcal meningitis: sudden onset
of fever, intense headache,
nausea/vomiting, stiff neck, may have
petechial rash (purplish pinpoint spots)
• Mumps: fever, swelling or tenderness of
salivary glands
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Symptoms of ATDs
(vary based on the disease)
• Tuberculosis: productive cough, fever,
unexplained weight loss
Overview of Tuberculosis
– TB is caused by Mycobacterium tuberculosis
– Can cause infection in almost any organ of
the body (secondary infections)
– Spread by droplet nuclei from infected person
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Classification of Tuberculosis
Class
Description
TB-0
No history of exposure, negative TST: No follow-up
TB-1
Contact, negative TST: Close contacts offered (window)
Prophylaxis
TB-2
Infected positive TST, no clinical, radiographic, or bacteriologic
evidence: LTBI criteria for INH
TB-3
Current disease may have positive TST, clinical, radiographic, or
bacteriologic evidence: Pulmonary & Laryngeal TB present
communicability risk
TB-4
Radiographic evidence of previous disease, positive TST,
adequate treatment, inadequate or no treatment, no current
clinical or bacteriologic evidence of disease
TB-5
Diagnosis pending, may have a positive TST, abnormal CXR,
cannot rule out active process: cough, wt loss, fever,
hemoptysis, noc sweats, positive smear or culture, ID pending
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Risk of Developing TB
• Persons at high risk for developing TB
once infected:
• HIV/AIDS – 10% risk per year
• Recently infected
• People who inject illicit drugs
• History of inadequately treated TB
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Risk of Developing TB (Cont.)
• Risk of Developing TB
– Certain medical conditions
• Diabetes
• End-stage renal disease
• Pulmonary fibrosis or silicotic process on
chest x-ray
• Gastrectomy
– Certain Drugs
• High dose cortisone/prednisone
• Methotrexate
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Precautions for ATDs
• Airborne Infection Isolation (AII)
– Negative Pressure Isolation
– UV light (TB)
– N-95 Respirator
• Required for Diseases such as:
– Measles
– Novel Influenza
– Smallpox
– Tuberculosis
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Pandemic H1N1 Influenza
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H1N1 Virus
• Is a type A Influenza Virus
• Human Infections occur and can spread
from person to person through coughing
and sneezing.
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H1N1 Virus (continued)
• A person can be infectious 1 day before
and up to 7-10 days after onset of
symptoms
• Symptoms: Fever > 100° F and an upper
respiratory illness with cough, may also
have nausea, vomiting, diarrhea or a sore
throat
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Specific Infection Control Precautions
Needed for Novel Influenza Viruses
Standard Precautions
 Effective Hand Hygiene (before and after
all patient contact)
Contact Precautions
 Use gloves and gown for all patient
contact
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Precautions needed for Novel
Influenza (continued)
Eye Protection
• Wear when within 6 feet of the patient
Airborne Precautions
• Place the patient in a negative pressure
isolation room
• Use at least a NIOSH approved N-95
respirator
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Vaccinia Virus
Virus used to make Smallpox vaccine does
not contain Smallpox virus. Similar to
Smallpox virus, but less harmful.
The vaccination site contains vaccinia virus
starting four (4) days after vaccination and up to
twenty-one (21) days.
• Not airborne – (Smallpox is airborne)
• Requires contact precautions
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Example of Vaccinia Virus infection.
Abdomen and chest of a 2-year-old boy with a rash of dimpled lesions caused
by eczema vaccinatum— a rare severe adverse reaction
caused by exposure to the vaccinia virus. Photo courtesy of John Marcinak
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Droplet Precautions
• Droplet precautions include procedures
designed to reduce the risk of transmission of
infectious agents through contact with
secretions.
• Required for diseases such as:
– Meningococcal disease (H. influenzae; Neisseria
meningitidis)
– Rubella
– Mumps
– Pneumonic Plague
– Pertussis
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Source Control Measures For
Persons with ATDs
• Procedures to minimize the spread of airborne
particles and droplets
• Important to educate patients with ATDs to cover
their cough and effective hand hygiene
• Patients must wear surgical mask not N-95
respirators
• Information can be communicated to patients via
posters/signs
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Scope of the ATD Standard
• A variety of health care facilities, services,
operations
• Hospitals, clinics
• Public health services (e.g. communicable
disease, contact tracing or screening)
• High risk environments
– Corrections
– Homeless shelters
– Drug treatment
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Four Types of Employers defined by
the Cal/OSHA ATD Standard
• Referring employers: don’t provide care beyond
initial to cases and suspected cases of AirIDs
diseases, and don’t do high hazard procedures
on them
• Full standard: hospitals and others that are not
referring employers
• Laboratories
• Conditionally exempt: dentists and outpatient
medical specialty practices that don’t treat ATDs
and have screening procedures
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Required Elements of the ATD
Standard
(Title 8, California Code of Regulations, Section 5199)
•
•
•
•
Identification of an Administrator
Written procedures/plans
Source control
Engineering, work practice, administrative
controls and PPE
• Respirators
• Communication
• Training
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Required Elements of the ATD
Standard (cont.)
(Title 8, California Code of Regulations, Section 5199)
• Recordkeeping
• Medical services
•
•
•
•
•
Vaccinations
Annual TB testing
Post exposure follow up
Precautionary removal
Respirator medical evaluations, if applicable
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Required Training
• Employers shall ensure that all employees with
occupational exposure participate in a training
program
• Employers shall provide training as follows:
– At the time of initial assignment to tasks where
occupational exposure may take place
– At least annually thereafter, not to exceed 12 months from
the previous training
– When changes, such as introduction of new engineering or
work practice controls, modification of tasks or procedures
or institution of new tasks or procedures, affect the
employee's occupational exposure or control measures.
The additional training may be limited to addressing the
new exposures or control measures
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Required Training
(cont.)
– Training material appropriate in content and vocabulary to
the educational level, literacy, and language of employees
shall be used
– An opportunity for interactive questions and answers
with a person who is knowledgeable in the subject
matter as it relates to the workplace that the training
addresses and who is also knowledgeable in the
employer’s infection control procedures
* The standard outlines the minimum elements that
must be included in the training program (refer to
the ATD Standard, pages 23-24)
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Exposure Determination Table
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High Hazard Procedures
•
•
•
•
Sputum induction
Transporting infectious ATD patients
Process ATP-L in the laboratory
Repairing, replacing or maintaining air
systems or equipment that may contain
ATDs
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List of Assignments or Tasks Requiring
Personal Protective Equipment
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Respiratory Protection Program
• All HCWs with occupational exposure to
ATDs must be fit-tested with a N-95
respirator
• Multiple use vs. Single use
• Effective September 1, 2010 Powered Air
Purifying Respirators (PAPR) must be
used for high hazard procedures
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Respiratory Protection Program
(cont.)
– Exception 1: If performed in a booth, hood
enclosure –may use N-95 respirator
– Exception 2: Paramedics and other
personnel in field operations may use a
P-100 respirator
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Specific Requirements for
Laboratories
• The ATD Standard requires lab employers to use
feasible engineering and work practice controls to limit
exposure and to provide PPE and respirators when that
equipment is necessary to control exposures
• The Public Health Laboratory is required to develop,
implement and annually review a written Biosafety Plan
(BSP) that includes the following:
• Safe handling procedures and list of prohibited practices
• Engineering controls, including containment facilities such
as biosafety cabinets
• Procedures requiring the use of PPE and/or respirators
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Specific Requirements for
Laboratories (cont.)
– Effective decontamination/disinfection procedures
– A requirement that all incoming materials
containing ATPs-L be treated as
containing the virulent or wild-type pathogen, until
proven otherwise
– Inspection procedures to be performed annually
– Emergency procedures for uncontrolled releases
within the lab & untreated releases outside the
lab, including reporting incidents to the local health
officer
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Medical Services for HCWs
• Medical surveillance – TB
– Routine screening
– Post-exposure screening
– HCWs with significant TST or Blood Assay Test (BAT)
• Latent TB Infection vs. TB Disease
• Risk Assessment for TB
– MDR – TB
– TB converters
5 to 10% will progress to active TB in 1-2 years
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Medical Services for HCWs
(cont.)
• Effective September 1, 2010 , recommended
vaccinations shall be made available to all employees
who have occupational exposure after the employee has
received the training required in subsection (c) or (i) and
within 10 working days of initial assignment unless:
– The employee has previously received the recommended
vaccination(s) and is not due to receive another
vaccination dose
– A PLHCP has determined that the employee is immune in
accordance with applicable public health guidelines
– The vaccine(s) is contraindicated for medical reasons
42
Medical Services for HCWs
(cont.)
• Recommended Vaccinations
–
–
–
–
–
–
Influenza – One dose annually
Measles – Two doses
Mumps – Two doses
Rubella – One dose
Tdap – One dose, booster as recommended
Varicella – Two doses
• Additional vaccine doses must be made
available to employees within 120 days of the
issuance of new applicable public health
guidelines recommending additional dose
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Medical Services for HCWs
(cont.)
• Declination statement required for employees
who decline a recommended and offered
vaccination (refer to Policy DOPH P-102)
• Must sign a statement for each declined vaccine
• Disease Control must inform Administration,
Human Resources and Occupational Health if a
recommended vaccine is not available
• Must check on vaccine availability at least every
60 calendar days and inform employees when
available
44
Occupational Exposure
• Work activity or conditions create an elevated risk of
contracting disease if protective measures are not in
place
– Elevated exposure risk vs. other public contact
operations
• Presumed for at least some employees in every facility,
service or operation listed in (a)(1)
• Examples:
– Direct contact with cases or suspected cases of ATDs
– Works within range of at-risk populations (e.g. homeless shelter
staff)
– Laboratory areas where ATPs-L are handled
– Contaminated equipment (e.g. AIIR ventilation systems)
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Post Exposure Follow-up for
ATDs
• Administrative procedures
– Employees must notify supervisor
– Supervisor evaluates exposure and ensures
required paperwork is completed
– Follow workers compensation procedures
– Must determine if employee had a significant
occupational exposure
– Must implement corrective measures if
indicated
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Precautionary Removal from
Work
• When a post exposure evaluation is done for exposure
to ATDs, or TB conversion, an assessment must be
made to determine if precautionary removal is needed to
prevent potential disease transmission
• If the PLHCP or the Public Health Officer recommends
precautionary removal, DOPH must maintain employee
earnings, seniority and other benefits until the employee
is cleared
47
Post Exposure Follow-up for
ATDs (cont.)
Depends on the ATD
• Novel Influenza
– Evaluation for post-exposure prophylaxis with
anti-viral medication
– Monitoring for development of signs and
symptoms
– Assess for need to exclude from work for 7-10
days
48
Post Exposure Follow-up for
ATDs (cont.)
• Pertussis
– Evaluation for post exposure treatment with
recommended antibiotics
– Monitoring for development of signs and
symptoms
– Assess for need to exclude from work
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Post Exposure Follow-up for
ATDs (cont.)
• Varicella
– Evaluation for antiviral therapy or varicella
vaccination (if given within 3 days)
– Monitoring for development of signs and
symptoms
– Assess for need to exclude from work (day
10-21)
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Post Exposure Follow-up for
ATDs (cont.)
• Measles
– Evaluation for measles vaccination or IG to be
given 72 hours of exposure
– Monitoring for development of signs and
symptoms
– Assess for need to exclude from work
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Referral of Patients with ATDs
• As part of the referral process, must notify
receiving HCF, PT has or suspected to
have an ATD.
• Transporting personnel (e.g. ambulance,
air transport) must be informed patient
has/may have ATD
• Patient must wear a surgical mask for
transport
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Containment of ATDs
• Triage of persons with respiratory symptoms to
be done by designated licensed staff
• Non-licensed staff must be educated to screen
persons with respiratory symptoms and refer to
licensed staff for triage
• Symptomatic patients must be placed in a
negative pressure isolation room or outside
• Prompt medical evaluation must be done by a
licensed health care professional
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Surge Procedures
• All DOPH employees are designated as disaster workers
and are expected to respond in an emergency
• Staff must complete NIMS/SEMS training and core
public health competencies at level I, II or III as
determined by supervisor/manager
• Each branch is to maintain an emergency notification
system
• Specific procedures for stockpiling and accessing
respiratory protection and PPE are part of the SNS and
DOPH Emergency Response Plans
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Zoonotic ATD Standard
• Zoonotic diseases /pathogens that are
transmissible from animal to humans
• Capable of causing human disease that
may be transmitted by droplets or an
airborne route
– Examples include:
• SARS
• TB
• H1N1 Influenza
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Scope of Zoonotic ATD
Standard
• Services that capture, sample, transport or dispose of
birds and other wildlife
• Farms producing animals or animal products
• Slaughterhouses
• Veterinary animal inspection
• Importers of live or untreated animals or animal products
• Zoos
• Animal parks
• Pet stores
• Laboratory operations
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Requirements of the Zoonotic
ATD Standard
• Establish procedures that minimize production of
aerosols
• Controls for cleaning and decontaminating
• PPE and respiratory protection
• Posting of signs in areas containing identified or
suspected cases
• Training
• Recordkeeping
• Provision of medical services to exposed workers
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A COMPLETE COPY OF THE AEROSOL
TRANSMISSIBLE DISEASE EXPOSURE
CONTROL PLAN
IS AVAILABLE AT CHA INSIDER’S PAGE
(under policies, procedures and guidelines tab)
http://intranet.rccha.org
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QUESTIONS
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