Jun 23, 2010 (CIDRAP News) – The US Centers for Disease Control and Prevention (CDC) yesterday posted updated proposed guidance for preventing pandemic H1N1 and seasonal influenza in healthcare settings, which relaxes some respiratory protection advice and stops short of recommending mandatory flu shots for healthcare workers.
The CDC said in a statement that it had planned to revise its earlier guidance as new information about the pandemic H1N1 virus became available. It also said changing circumstances have justified recommendation changes. A safe and effective vaccine against the pandemic H1N1 virus is now widely available, and the agency now has a better picture of the number of cases, hospitalization, and deaths, which indicate that the impact of virus is substantially lower than its prepandemic assumptions.
Another goal of the proposed revised guidance is to consolidate recommendations for seasonal flu in healthcare facilities from different CDC sources into one guidance document that also covers pandemic H1N1 flu. "In updating this particular guidance, CDC will consolidate recommendations into a comprehensive, easily accessible document," the CDC said.
In posting the proposed guidance, the CDC asked individuals and groups to review and comment on the new guidance by July 22 and said it would publish the final guidance before the 2010-2011 flu season.
The guidance says that although flu viruses are thought to primary spread though large-particle droplets that travel relatively short distances, contact transmission may be possible and airborne transmission in small-particle aerosols may also occur. It added that the contribution of different transmission modes is not clear. In addition, respiratory secretions and body fluids, including diarrhea stools, of patients who have influenza are also considered potential infectious.
Vaccines and minimizing exposure
At the top of the list of recommendations is advice to promote and administer seasonal flu vaccine to healthcare personnel. Strategies to improve uptake can include offering incentives, providing free vaccine, improving access to vaccines, and requiring staff to sign declination forms to show they are aware of the risks and benefits of vaccination.
However, the CDC acknowledged that mandatory vaccination is controversial. In October 2009, the pandemic H1N1 vaccine shortage prompted the state of New York to suspended its mandatory flu vaccination requirement for healthcare workers a week before it faced a court hearing involving one of New York's largest employee unions, which sued the state over the mandatory flu shot law.
To minimize exposure to flu in the healthcare setting, the guidance says a range of administrative practices can be used before sick patients arrive, when they arrive, and throughout their visits.
In addition to promoting hand and cough hygiene practices, the CDC suggests that facilities can, for example, ask patients with flu-like symptoms to wear face masks in triage areas or establish systems, such as flu call lines, that can prevent patients without risk factors who have mild infections from coming to emergency departments.
To address employee health issues, the guidance provides detailed information on how and when workers with flu should return to work. For example, the CDC advises that clinicians who work with high-risk patients, such as hematopoietic stem cell transplant recipients, should be temporarily reassigned or stay home for 7 days, though they can return sooner if real-time reverse transcriptase polymerase chain reaction (rRT-PCR) testing shows no more evidence of the virus
In the section about standard precautions, the CDC recommends that droplet precautions be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after fever and respiratory symptoms resolve, whichever is longer.
Masks vs respirators
In a change from previous pandemic H1N1 recommendations, the CDC advises that healthcare workers wear face masks when entering the room of a patient who has confirmed or suspected flu. Earlier recommendations suggested that staff wear N-95 respirators during all contact with flu patients; however, the new guidance recommends N-95s or higher levels of protection during risky procedures such as aerosol-generating procedures. The CDC also recommends conducting higher-risk procedures in negative pressure rooms when available.
The CDC's earlier N-95 recommendation stirred controversy among healthcare workers and some professional medical groups, who said wearing N-95s during all interactions with flu patients was uncomfortable and impractical for healthcare staffs.
In November 2009, three groups—the Association for Professionals in Infection Control (APIC), the Infectious Diseases Society of America (IDSA), and the Society for Healthcare Epidemiology of America (SHEA)—sent a letter to President Obama criticizing federal officials' interpretation of the scientific data on surgical masks and N-95 respirators and charging that CDC and Occupational Safety and Health Administration (OSHA) requirements about N-95 respirators were confusing healthcare workers and wasting scarce resources. In their letter the groups urged the Obama administration to relax the N-95 recommendation and order a moratorium on the enforcement of an OSHA requirement to use N-95s in H1N1 settings.
The new guidance also covers several other areas, including handling visitors, surveillance, environmental controls, training, antiviral treatment and prophylaxis, and how to protect healthcare workers who are themselves at higher risk for flu complications.
Representatives from APIC, IDSA, and SHEA said their administrators were reviewing the CDC's new guidance and plan on submitting feedback.
SHEA president pleased
Neil O. Fishman, MD, president of SHEA, told CIDRAP News that he was pleasantly surprised by what the CDC included in the guidance. "I was glad to see the recommendation for face masks for general care," he said. The new recommendation also reflects the latest scientific evidence, which suggests that in general care settings, N-95s don't provide a protective advantage over face masks, said Fishman, who is director of healthcare epidemiology and infection prevention at the University of Pennsylvania.
One worry that Fishman and his staff had about the earlier guidance suggesting N-95s for general care is that heavy use of the devices might deplete their supply, leaving facilities without enough to respond to an event in which they were truly needed, such as a tuberculosis outbreak.
He also welcomed the guidance about performing high-risk procedures in negative pressure rooms whenever possible.
Fishman said his only disappointment with the document is lack of a stronger statement about mandatory flu vaccines for healthcare workers.
Addressing both pandemic H1N1 and seasonal flu in one document sends a clear message that they should be considered together, he said. Over the course of the pandemic, researchers learned the virus behaved much like seasonal flu, and management should be no different, Fishman added.
Jun 22 Federal Register notice
Jun 22 CDC statement