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2009 H1N1 Influenza
DOSH Directive 11.70
H1N1 Influenza
• In April 2009, a novel H1N1
influenza A strain of swine
origin was identified in
Mexico. It was designated
as novel because it was
genetically distinct from the
circulating seasonal flu virus
and therefore humans had
little or no immunity to it and
there was no vaccine to
protect against it.
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State Plan Policy
• States with OSHA-approved State Plans must
adopt OSHA’s enforcement policies or have their
own enforcement policies that must be at least
as effective as OSHA’s.
• DOSH has elected to adopt its own Directive
closely following OSHA’s.
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Publications Referenced
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Purpose
• …to minimize high to very
high occupational
exposure risk to the virus
identified as 2009 H1N1
influenza of workers
whose occupational
activities involve contact
with patients or
contaminated material in
a healthcare or clinical
laboratory setting.
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Scope
• Inspections will be conducted in workplaces
where healthcare workers will likely have high to
very high risk exposure to 2009 H1N1 influenza.
Hospitals, medical clinics, doctors’ and dental
offices are most likely to have these type
exposures.
Scope (continued)
• Non-healthcare settings that provide
clinical services may also be covered,
including:
– Schools
– Correctional facilities
• Reference available CDC guidelines for
specific settings
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DOSH Directive 11.70
Effective Date: 12-23-2009
Subject: Enforcement
Procedures for High to Very
High Occupational
Exposure Risk to 2009
H1N1 Influenza
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Definition of a Healthcare Worker
• Healthcare personnel all persons whose
occupational activities involve
contact with patients or
contaminated material in a
healthcare or clinical
laboratory setting.” … many of
which include patient contact
even though they do not
involve direct provision of
patient care, such as dietary
and housekeeping services.
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• Work settings include:
– Inpatient and outpatient
facilities,
– Home healthcare settings,
and
– Institutional settings such
as schools and correctional
facilities.
Very High Risk Exposure
• 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.
– Performance of aerosol-generating procedures on
patients with suspected or diagnosed 2009 H1N1
influenza; or
– Manipulations of influenza laboratory specimens that
may create aerosols.
Aerosol-Generating Procedures
• The aerosol-generating
procedures include:
– Bronchoscopy
– Sputum induction
– Endotracheal intubation
and extubation
– Open suctioning of airways
– Cardiopulmonary
resuscitation
– Autopsies
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High Exposure Risk
• A job task or activity involving a high
potential for exposure to suspected or
confirmed 2009 H1N1 influenza virus,
such as:
 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).
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Hierarchy of Controls
• Facilities should use a hierarchy of controls
approach to prevent exposure of healthcare
personnel and patients and prevent influenza
transmission within healthcare settings.
• Eliminating the potential source of exposure
ranks highest in the hierarchy of controls.
Hierarchy of Controls (continued)
• 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
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Hierarchy of Controls (continued)
• 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
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Inspection Scheduling
Compliance Inspections
•
•
•
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Focus is on hospitals, emergency medical centers, doctors’
and dental offices and clinics.
Inspections will be opened in response to formal complaints
and referrals
Where complaints or referrals are received regarding nonhealthcare settings or regarding medium and low risk exposure
risk response will be via phone/fax.
Inspection Procedures
Opening Conference
• CSHOs shall establish whether the workplace has employees
who may carry high or very high exposure risk.
• CSHOs must request information on any hazard assessment or
exposure risk assessments performed at the facility for the
following:
•
•
•
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Any assessment to determine the presence of hazards which
necessitate the use of personal protective equipment (PPE)
Initial respiratory hazard evaluation.
Exposure risk assessment to determine employees’ exposure risk
categories.
Opening Conference (continued)
•
CSHOs shall initially determine whether the
employer has a written pandemic influenza plan as
recommended by the CDC.
•
•
The evaluation of an employer’s pandemic influenza plan may
be based upon written programs and, in a hospital, a review of
the infection control data.
Other information which may be reviewed includes:
•
•
•
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medical records related to worker exposure incident(s),
OSHA 300 log, and
any other pertinent information or documentation deemed
appropriate by the CSHO.
Walkaround
• CSHOs shall use professional judgment in determining
which areas of the facility will be inspected (e.g.,
emergency rooms, respiratory therapy areas,
bronchoscopy suites, morgue).
• Photographs or videotaping where practical shall be
used for case documentation…under no
circumstances shall photographing or videotaping of
patients be done, and
• CSHOs must take all necessary precautions to assure
and protect patient confidentiality.
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Compliance Officer (CSHO) Protection
•
CSHOs shall use
judgment and exercise
caution:
• Conduct inspections in a
manner that minimizes or
prevents exposure (for
example, view employee
work tasks through an
observation window).
Example: observe procedures
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CSHO Protection (continued)
•
CSHOs shall not enter rooms occupied
by 2009 H1N1 influenza patients or
airborne infection isolation rooms
(AIIRs) to evaluate compliance.
•
•
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If CSHOs must enter a vacant AIIR,
sufficient time must lapse before entry
can be made. (For information on
clearance rates under differing
ventilation conditions, see
http://www.cdc.gov/mmwr/preview/mmw
rhtml/rr5417a1.htm).
CSHOs shall practice social distancing
(such as maintaining at least 6 feet of
distance), if possible, while conducting
interviews with employees or patents
with suspected influenza .
CSHO Protection (continued)
• CSHOs must ask employers if there
are any PPE requirements. Where
CSHOs need to test ventilation or air
flow of an isolation room – CSHOs
shall wear a half-mask negative
pressure respirator with at least N95
filters.
• CSHOs shall wash their hands with
soap and water after each inspection
or use hand sanitizers if handwashing
facilities are not immediately available.
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Records Review
•
Access to employee medical and
exposure records.
•
•
Follow the direction contained in WAC 296-802500 when accessing employee medical records.
Consult with the DOSH Occupational Nurse
Consultant for further guidance.
Note: HIPAA does not apply to employee health
information.
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[p. 12]
Records Review (continued)
•
OSHA 300 Log
•
•
Illnesses due to the 2009 H1N1 influenza are not considered a
common cold or seasonal flu.
Employers are responsible for recording cases of 2009 H1N1
illness if all of the following requirements are met:
1.
2.
3.
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the case is a confirmed case of 2009 H1N1 illness as defined by CDC;
the case is work-related as defined by 296-27-01101; and
the case involves one or more of the recording criteria set forth in 296-2701107 (e.g., medical treatment, days away from work ).
Review 296-27-01107-General Recording
Criteria
• An injury or illness is recordable if it results in one or
more of the following:
–
–
–
–
–
–
–
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Death
Days away from work
Restricted work activity
Transfer to another job
Medical treatment beyond first aid
Loss of consciousness
Significant injury or illness diagnosed by a Physician or Other
Licensed Health Care Professional (PLHCP)
Citation Guidelines
• Applicable Standards








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296-800-110 Safe Place Standard.
296-800-11045 Biological Agents
296-800-140 Accident Prevention Program
296-27 Recordkeeping and Reporting.
296-800-160 Personal Protective Equipment.
296-842 Respirators
296-800-220 Housekeeping
296-802 Employee Medical and Exposure Records.
Citation Guidelines (continued)
Citation Review
• Safe Place citation:
• The proposed citation shall be reviewed by:
• DOSH Compliance Manager; and
• Occupational Nurse Consultant, prior to issuance.
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Respiratory Protection Requirements
High exposure risk:
• Entering rooms with suspected
or confirmed 2009 H1N1
influenza patients,
• Attending to suspected or
confirmed 2009 H1N1
influenza patients through
close contact (within 6 feet), or
• Transporting suspected or
confirmed 2009 H1N1
influenza patients in enclosed
vehicles.
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Very high exposure risk:
Aerosol-generating
procedures:
• Bronchoscopy,
• Sputum induction,
• Endotracheal intubation
and extubation,
• Open suctioning of
airways,
• Cardiopulmonary
resuscitation and
• Autopsies
Respiratory Protection (continued)
• respiratory protection
must be at least as
protective as a fit-tested
disposable N95 filtering
facepiece respirator.
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• Respiratory protection
must be donned prior to
entering a 2009 H1N1
influenza patient’s room.
Respiratory Protection Citations
• 296-842-13005 – Failed to conduct an
initial hazard evaluation
• 296-842-13005 - Fails to select and
provide appropriate respirator
• 296-842-12005 – Failure to have a
written program when respirators are
required
• 296-842-15005 – Failure to have initial or
annual fit test
• 296-842-17015 – Fails to ensure
respirators are inspected
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Respiratory Protection (continued)
•
Respirator Shortage: …extended use or re-use of N95 respirators
is permitted, …
•
•
•
•
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As long as the respirator maintains its structural and functional
integrity and
the filter material is not physically damaged or soiled.
Employers must address in their respiratory protection program
the circumstances under…considered to be contaminated and not
available for extended use or re-use.
Guidance on reuse of respirators can be obtained from the CDC’s
website at:
www.cdc.gov/h1n1flu/guidelines_infection_control_qa.htm
Respiratory Protection (continued)
Citations shall be issued
for the failure to provide
a respirator at least as
effective as an N95
filtering facepiece
unless the employer
can establish all of the
items listed:
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 There is a shortage of respirators that are at least
as effective as an N95 respirators or better;
 The employer made a good faith effort to obtain
other alternative respirators such as N99, N100 or
reusable elastomeric respirators;
 The employer made an effort to monitor their supply
of N95s and to prioritize their use according to CDC
guidance;
 Surgical masks and eye protection devices were
provided as an interim measure to protect against
splashes and large droplets and
 Other measures were instituted to protect
employees, for example, use of partitions or other
engineering controls that might reduce the need for
PPE or reducing exposure through cohorting
patients.
Citation Guidelines (continued)
•
Other Personal Protective Equipment (PPE) Standards
•
•
•
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Cite 296-800-16005 - Where an employer fails to conduct a hazard
assessment to determine the need for PPE … to protect an
employee’s eyes, as well as mouth and nose, from splashes, droplet
sprays, and from autoinoculation of influenza virus from the fingers or
hands.
Cite 296-800-16020 - When there is an established shortage of
respirators and surgical masks are not provided and used.
Cite 296-800-16050 - Where an employer fails to provide or ensure
the use of PPE that is needed to protect against splashes, droplet
sprays and autoinoculation of influenza virus from the fingers and
hands.
Safe Place
•
•
•
Safe Place Standard violations are based on the hazard of
exposure to the 2009 H1N1 influenza.
CSHOs shall evaluate whether an employer has implemented
engineering controls, for abatement of the hazard.
Potential engineering controls to be considered include:
•
•
•
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AIIR rooms used for performance of aerosol-generating procedures
are maintained under negative pressure;
Where AIIR rooms are not available, whether the employer has
increased air changes and eliminated/minimized unfiltered
recirculation of the room air;
Whether the employer has installed sneeze guards, windows at
clerical intake areas or other barriers between workers and the
general public (if feasible) to prevent transmission of the 2009 H1N1
influenza.
Safe Place (continued)
•
Administrative controls:
•
•
•
•
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Ensuring that unprotected healthcare personnel are not allowed in
rooms where an aerosol-generating procedure has been conducted
unless the employer establishes that potentially infectious particles
have been removed or minimized;
Screening and limiting access of sick visitors; implementing a system
for expeditious triage, isolation and/or cohorting of suspected
pandemic patients.
Encouraging employees at high to very high occupational exposure
risk to get the 2009 H1N1 influenza vaccination and provide it at no
cost.
Offering early treatment with antiviral medications after unprotected
exposure.
Citation Guidelines (continued)
•
Other DOSH Standards Commonly
Associated with Healthcare Employers
•
•
•
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Bloodborne Pathogens. Compliance is
required as per 296-823.
Sanitation. Surfaces potentially contaminated
with 2009 H1N1 influenza virus should be
decontaminated pursuant to 296-800-22005.
Specification for accident prevention signs and
tags. Warning signs shall be posted outside
the entrance of isolation or treatment rooms in
accordance with 296-800-110459(2) A
description of the necessary precautions (e.g.,
“respiratory protection must be donned before
entering”) should be included in the warning.
WIN Tracking
• Please use the Dropdown box to code
inspections with:
H1N1
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Resources Online
• Worker & Employer Guidance
for responding to H1N1 Flu
Links to Other Resources:
• DOH.wa.gov
• Flu.gov
• HHS/CDC - H1N1 Flu
• WHO - Pandemic (H1N1)
• OSHA's Pandemic Influenza
Directive CPL 02-02-075
• NIOSH - H1N1
• CDC.gov
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Questions
John Furman, ONC (360-902-5666 or
[email protected]) may be contacted with any
questions
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